LIBRARY J)^F CONGRESS, 

Cliap Copyright Ko 



I UNITED STATES OF AMERICA. 




INFANT-FEEDING 



N ITS RELATION TO 



Health and Disease 



t/ BY 

LOUIS FISCHER, M.D. 

Atteuding Phj'sician to the Childreu's Service of the New York Germau Tolikliaik : Former 
Instructor in Diseases of Children in the New York Post-graduate Medical School and Hos- 
pital : Bacteriologist to St. Mark's Hospital ; Professor of Diseases of Children in the New- 
York School of Clinical Medicine; Secretary' of the Section of Diseases of Children 
of the American Medical Association ; Attending Physician to the Children's 
Department of the "West-side German Dispensarj' : Consulting Physician on 
Diseases of Children to the United Hebrew Charities; Consultant to the 
Messiah Home for Children; Fellow of the New York Academy of 
Medicine; Former President of the Eastern Medical Society and 
of the Society for Medical Progress, etc., etc., etc., etc. 



Containing 52 Illustrations, with 23 Charts and 
Tables, Mostly Original 




Phii.adelphia, Chicago 

F. A. DAVIS COMPANY, PUBLISHEKS 

1901 



THE LIBRARY OF 

CONGRESS, 
Two Copies Received 

MAR. 5 1901 

Copyright entry 

CLASS Ct XXc. No 

COPY 8. 



\ 






COPYRIGHT, 1901. 

BY 

F. A. DAVIS COMPANY. 

[Registered at Stationers' Hall,.LuiRloii. Eng.] 



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The Medical Bulletin Printing-house. 
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THIS BOOK 

IS 

DEDICATED TO MY FRIEND, 
DR. GEORGE F.SHRAUY, 

AS A 

TOKEN OF RESPECT 

AxD FOR His Sterling Qualities as a Man axd 
His Sincerity as a Physician. 



PEEFACE. 



DuEi^^G ten years' experience in the children's serv- 
ice of one of the largest children's clinics in this conntr}' 
the author has met with many intricate prohlems in 
infant-feeding. Besides this, many points were gained 
while studying abroad through the wise counsel of Pro- 
fessor Adolf Baginsky at the Kaiser and Kaiserin Friedrich 
Children's Hospital in Berlin, both in his hospital wards as 
well as in the out-patient department. 

"Wliile lecturing on diseases of children at the New 
York Post-graduate School and Hospital, and later while 
instructing at the New York School of Clinical Medicine, 
the author has noted the great anxiety with which his 
students, all of whom were physicians in active practice, 
requested detailed information regarding the "Modern 
Methods of Infant-feeding.'' 

The author has therefore felt that if his experience, 
aided by the suggestions of many good text-books, w^ere 
combined to give details pertaining to the feeding of 
infants and children requiring breast-feeding or hand- 
feeding, — so-called bottle-feeding, — then his work would 
serve as a guide to both the active practitioner and also 
to the beo'inner in medicine. 



Louis Fischer. 



65 East Ninetieth Street, 
New York City. 



(^) 



TABLE OF CONTENTS. 



PART I. 

PAGE 

Chapter I. — Anatomy and Physiology of the Infantile 

Stomach 1 

Chapter II. — Action of Digestive Ferments on Various 

Bacteria 4 

Chapter III. — Stomach-capacity G 

Chapter IV. — Ferments and Their Actions 11 

Chapter V. — The Intestinal Canal of the Infant 15 

Chapter A'I. — Fermentation and Absorption 18 

Chapter VII. — Constituents of Milk 25 

Chapter VIII. — Bacteria of the Intestine 40 

Chapter IX. — Variations of Milk 57 

Chapter X. — Chemical Examination of Breast-milk 62 

Chapter XL — Breast-feeding and Mixed Feeding 68 

Chapter XII. — Wet-nursing and Weaning 78 

Chapter XIII. — Management of Woman's Xipples 90 

Chapter XIV. — Infant's Weight 94 

Chapter XV.— Raw Cows' Milk 100 

Chapter XVI. — Constituents of Cows' Milk. Ill 

Chapter XVIL— Cream and Modified Milk 133 

Chapter XVIII. — Water as an Infant's Beverage 142 

Chapter XIX. — Bottle-feeding 144 

Chapter XX. — Feeding-table and Cream-mixtures 145 

Chapter XXI. — Home-modification of Milk 148 

Chapter XXII.— Sterilized Milk 158 

Chapter XXIII. — Pasteurized Milk 167 

Chapter XXIV.— Tyndallization 174 

(Yii) 



Mil CONTENTS. 

PAGE 

Chapter XXV.— Nipples uiul Bottles 170 

Chapter XXVL—nextrinized Gruels 183 

PART II. 

Chapter XXYII. — Incubator-feeding 186 

Chapter XXVIII.— Aerated and Certified Milk 197 

Chapter XXIX.— Infant-foods 199 

Chapter XXX.— Condensed Milk 212 

Chapter XXXI. — The Feeding of Diphtheria-Intubation 

Cases 242 

Chapter XXXIL— Forced Feeding 244 

Chapter XXXIIL— Modified Milk 247 

Chapter XXXIV.— Infant-stools 205 

Chapter XXXV. — X'athan Straus Milk-laboratories and Sim- 
ilar Charities 273 

Chapter XXXVI.— Colic 270 

Chapter XXXVII.— Constipation 280 

Chapter XXXVIIL— Statistics 292 

Chapter XXXIX.— Rachitis 294 

Chapter XL. — Dentition 300 

Chapter XLI. — Athrepsia Infantum (Marasmus) 304 

Chapter XLIL— General Rules for Rectal Feeding 320 

Chapter XLIIL— X'asal Feeding 322 

Dietary 324 

List of Books Consulted 349 

IXDEX 351 



PART I. 
CHAPTER I. 

Inteoductiois'. 

To PEOPEELY Lmclerstand the difference between the 
varions forms of infant-feeding it is necessary to consider 
the anatomy and physiology of the very yonng digestive 
tract. 

The infantile stomach is vertical and cylindrical and 
the fnndns bnt little developed. Thus, whenever there 
is a tendency to vomit, the antiperistaltic motions do not 
press against the fnndns, bnt directly npward. There is, 
therefore, less gennine vomiting than a mere overflow of 
the gastric contents, which takes place so easily that the 
babies are not disturbed by it.^ 

AX ATOMY. 

The muscular development is weakest at the fundus. 
According to Fleischmann, the fibra? oblique and the longi- 
tudinal fibres described by Henle, which have their origin 
at the pyloric opening, "^do not 'exist in the infant." In 
spite of this lack of muscular development, the investiga- 
tion of Leo and von Puteren show that the gastric con- 
tents of nursing infants are propelled within from one and 
a half to two hours. With food that is more diihcult to 
digest the stomach is emptied much slower and less com- 
plete. 

The Mucous Memirane of the Stomach. — The mucous 



^ Jacobi. "Therapeutics of Infancy and Childhood." page 2.5. 

(1) 



X INFANT-FEEDING. 

i;"laiuls aiH* tar more uuiuerous on tlie pars pylorica than 
in adults, whereas they are far fewer in number at the 
cardia. 

The mucous membrane of the infant secretes a gas- 
tric juice which, in general, is similar in properties to 
that of the adult. The secretion in the infant is far less 
than in the adult, but its chemical constituents are like 
the adult, namely: pepsin, lab-ferment, and acids. The 
exact proportion of a ferment and pepsin has not yet 
been sufficiently studied to base positive deductions there- 
from. 

PHYSIOLOGY. 

It is very important to know that the mucous mem- 
brane of the mouth is practically dry at birth, and the 
secretion of saliva very small, and increases toward the 
end of the second month, according to Korowin and 
Zweifel. 

The fermentative (sugar-forming) property of saliva, 
which is trifling at the commencement, increases with the 
quantity of the saliva secreted. This is essentially true of 
other secretions; thus, the pancreatic juice does not have 
the same emulsifying properties in the infant as in adults. 

The nursing or sucking centre is located, according 
to experiments made on animals by Basch, in the medulla 
oblongata on the inner side of the corpus restiforme. 

The sucking act is reflex; according to Auerbach, 
the muscles of the tongue participate most actively. 

Acids in the Infant's Stomach. — The gastric contents 
in a nursling contain two acids: (1) hydrochloric acid; 
(2) lactic acid. The relative acidity is smaller than in 
adults, the highest point being reached one and a half 
hours after nursing. According to Puteren, the acidity 



INTRODUCTION". 6 

is 2 Y2 ^0 3 times as small as in the stomach of adults. 
According to Leo, the acidity of the gastric jnice of nurs- 
lings 1 ^/g hours after drinking is only 0.13 per cent., 
whereas, in the adult at the same time, the acidity is from 
1.5 to 3.2 per cent. According to Wohlmann, the free 
HCl in healthy nurslings can he found from 1 V4 fo 2 
hours after taking food. The percentage of free HCl 
ranges from 0.83 to 1.8 per cent. 

Lactic Acid. — The quantity of lactic acid is, accord- 
ing to Heubner, between 0.1 and 0.4 per cent. 

Pepsin and Hydrochloric Acid. — There are two chief 
functions of the pepsin and hydrochloric acid which are 
the same in both infant and adult: First, the power of 
killing hacteria: a real antibactericidal power. Second, 
as a solvent for alhumin. Thus, it is apparent that pa- 
thogenic micro-organisms that might have entered the 
stomach can he destroyed, although we know the small 
quantity of acid is hardly able to cope with large quanti- 
ties of food contaminated with bacteria. 



CHAPTBK II. 

Action of the SxVliva on Various Bacteeia. 

Triolo- describes a series of interesting experiments 
with saliva. He first irrigated the month with bichloride 
or permanganate-of-potash solntion, followed by irriga- 
tion with sterilized water nntil the disinfecting substances 
were removed, and then inocnlated the surface of various 
culture-media with the sputum. His results proved that 
saliva possesses a distinct antibactericidal property, for 
cultures of five-day-old bacteria were destroyed, as well 
as fresh bacteria eighteen hours old. 

This property, however, was lost when saliva was 
filtered. The saliva of the parotid and submaxillary 
glands, taken singly, were equally efficacious as their com- 
bined secretion. He believes that the greatest bacteri- 
cidal action is due to the secretion of the mucous glands 
in the mouth. 

The Influence of GtAstric Juice on Pathogenic 

GrERMS. 

Gastric juice is, according to the experiments of Drs. 
Kurlow and Wagner,^ an exceedingly strong germicidal 
agent, and when living bacilli get into the intestinal canal 
it is due to various conditions entirely independent of the 
gastric juice. When the latter is normal and in full ac- 
tivity, only the most prolific microbes — such as tubercle 
bacilli, the bacilli of anthrax, and perhaps the staphylo- 



- Rivista d'Igiene e di Med. Prat., Neapel. 
^Vracht; Lancet, March. 22, 1890. 

(4) 



IN"FLUENCE OF GASTEIC JUICE. 5 

cocci — escape its destructive action; all others are de- 
stroyed in less than half an hour. Similar influences exist 
in the intestines^ as proved by inoculation with the cholera 
bacilli. 

Judging from the results of experiments made by 
Zagari. Straus^ and AYurtz, who exposed various pathog- 
enic organisms^ among others that of tuberculosis^ to the 
action of gastric juice, we must come to the conclusion 
that, so long as the gastric juice retains a sufficient degree 
of acidity, tuberculosis of the alimentary canal will be un- 
likely to occur. "^ 



* Canadian Practitioner, April 1, 1890. 



CHAPTER III. 

Stomach-capacity. 

At birth the infant's stomach has a capacity of from 
9 to 11 drachms, or 35 to 43 cubic centimetres. 

At the end of 1 month it is about 2 ounces^ or 60 cubic 
centimetres. 

At the end of 3 months the gastric capacity is about 
4: times the amount at birth. This very rapid increase 
from birth to. this time soon ceases, and the stomach ca- 
pacity grows in size, but at a much slower rate of develop- 
ment. (Baginsky.) 

The series of experiments at the Children's Hospital 
at St. Petersburg, made by Ssnitkin, showed that the 
weight, and not the age, determined the capacity of the 
stomach, and should be used as a guide for the quantity 
of infant-food required. 

If the normal (initial) weight of an infant is 3000 
to 4000 grammes, or about 6.6 to 8.8 pounds, then ^/.^oo 
part, plus the daily increase in weight added, which nor- 
mally amounts to ^/g-l ounce, would give the amount of 
food required. 

Biedert also regards the body-weight as an important 
factor in determining the amount of milk to be given, but 
Baginsky argues that, while this rule will hold good for 
a great many infants, he must insist on relying upon the 
scales to show just how much nutriment has been di- 
gested, and thus a regular system of weighing plus the in- 
spection of the stools will aid in establishing the quantity 
of food necessary. "There is no unanimity among experi- 

(6) 



. BTOMACH-CAPACITY. 7 

ciiced clinical observers upon the subject of infant-feed- 
ing." Thus, for example, while the great majority of 
clinicians the world over order milk (cows^) in varying 
dilutions, some using the cereals — like wheat, barley, rice, 
and farina — to dilute and subdivide the curd, other clin- 
ical observers — Budin and Yariot, French observers — ad- 
vise giving infants at hirth tvliole milk; that is, pure, un- 
diluted coivs' milh. 

The following illustrations ^vill serve to show the dif- 
ference in the capacity of infants^ stomachs at various ages, 
taken ly the author at the morgue of BeUevue Hospital: — 




Fig. 1. — Infant's Stomachy 1 Month Old. Actual Size. From a 
Case of Malnutrition. Capacity, about 2 Ounces. When 
Stomach was Filled it Held 4 Ounces Easily. (Author's 
Collection.) 



INFANT-FEEDING. 




fl .-t^ 


s ^ - 


OO s2 


'g^l 


> ■— 1 -M 


C •'^ « 


o !^ ^ 


^ . o 


from 
whei 
r's C 


f>> ^ r^ 


'-; -Th -(J 


C O p3 


■s a<fl 




rt 


rd • 1^ 


S =^ S 


fi|1 


S (^ 


05 § 02 


N '-^ ^ 


^ H g 


,— ( ^ ?-( 


ce ^ ^ 


f3 -t^ ^ 


-M cS « 


' ^R 1 


,:^ 5-1 


. O P 


Stomach 
. Cause 
unces. ( 


.«2 S O 
if +3 ^ 


S « \ 


o3 o " 


fig- 


1 t- %^ 


1 1^ 


":|| 




S 



STOMACH-CAPACITY. 




10 



INFANT-FEEDTNG. 





X 




^ >v 



' Q 



CHAPTEE IV. 

Feements and Their Actions. 

Ix newborn children the parotid alone contains ptya- 
lin. The diastasic ferment seems to be developed in the 
submaxillary gland and pancreas at the earliest after two 
months. Hence it is not advisable to give starchy foods 
to infants. 

Ptyalin, the diastase of the saliva, a hydrolytic fer- 
ment, or enzyme, of the group of unorganized ferments, 
acts only within a certain range of temperature, being 
most active about 40° C. It acts best in a slightly- 
alkaline or neutral medium. Its action is permanently 
destroyed by boiling. 

Amylopsin, the diastasic ferment of the pancreatic 
juice, seems to be identical with ptyalin, but it acts much 
more energetically on raw starch, as well as upon boiled 
starch; at the temperature of the body the change is al- 
most instantaneous. At a low temperature this change 
takes place slowly. 

According to Musculus, O^Sullivan, and von Mering, 
ptyalin and amylopsin change starch and glycogen (animal 
starch) into dextrin and maltose. 

Erythrodextrin is first formed, then a chroo dextrin, 
and, from achroodextrin, maltose. At 40° C. maltose is 
slowly changed into dextrose. (Landois and Sterling.) 

Dextrose and maltose turn the plane of a ray of 
polarized light to the right. The general term grape- 
sugar was used formerly to include dextrose (glucose) and 
maltose. 

The existence of maltose (though described by Du- 

(11) 



12 INFANT-FEEDING. 

brunfaut in 184?) was for a long time doubted until 
O^Sullivan^ in 1872, confirmed the previous experiments. 
(Foster.) 

In commerce the term ''grape-sugar'' is applied to the 
solid product of the "grape-sugar works/' the liquid 
product being known as "glucose." 

Maltose is the end-product of the action of malt- 
diastase on starch, and can be also formed as an inter- 
mediate product in the action of dilute sulphuric acid on 
the same substance. It also appears to be the chief sugar 
formed from starch b}^ the diastasic ferments contained 
in the saliva (ptyalin) and pancreatic juice (amylopsin). 
(Halliburton.) 

The diastasic action of succus entericus, the fluid of 
the small intestine, is incomparably weaker than ptyalin 
or amylopsin, and seems only to continue their action. 
According to Schifl, Busch, Quincke, and Garland, it does 
not form maltose from starch (Eichhorst states that the 
juice of the large intestine will do this), but changes mal- 
tose, which is usually the ulterior product obtained by the 
action of ptyalin and amylopsin, into dextrose. The 
greater part of the maltose is absorbed unchanged. Mal- 
tose and dextrose are both crystalline. 

Bourquelot thinks that the change from maltose to 
dextrose is due to the action of the intestinal schizomy- 
cetes, and not to the intestinal juice as such, the saliva, 
gastric juice, or invertin. (Landois and Sterling.) 

An important property of dextrose is its power of 
undergoing fermentations. When an aqueous solution of 
dextrose is submitted to the influence of yeast, alcoholic 
fermentation results, yielding alcohol and carbonic an- 
hydride. Lactic fermentation occurs in the presence of 
decomposing nitrogenous matter, especially of casein, and 



FERMENTS AND THEIR ACTIONS. 13 

is 23robably the result of the action of a specific ferment. 
The first stage is the production of hictic acid; in the 
second, butyric acid is formed, with evohition of hydrogen 
and carbonic anhydride. (Foster.) 

Ghicose is easily fermentable. (Laiidois and Ster- 
ling.) 

The glucoses are the only sugars capable of direct 
fermentation; of these, dextrose is more readily decom- 
posed by yeast than is l^eTulose. 

Certain other sugars are capable of indirect fer- 
mentation by yeast; among these are cane-sugar and mal- 
tose; they are first, however, hydrolyzed to glucose. 
(Jago.) 

Sucrose (cane-sugar) is not readily absorbed by the 
intestinal mucous membrane until it has been transformed 
into glucose. 

Glucose (like maltose) is taken directly into the cir- 
culation. (Flint.) 

The gastric juice slowly changes cane-sugar into glu- 
cose. 

According to CI. Bernard, invertin in the intestinal 
juice converts cane-sugar into invert-sugar, which is a 
mixture of l^vulose and dextrose. (Landois and Sterling.) 

Dilute acids convert cane-sugar into invert-sugar, 
which consists of equal parts of dextrose and iBevulose. 

When subjected to the action of ferments, cane-sugar 
is first transformed into invert-sugar, then into alcohol 
and carbonic acid (vinous fermentation). (Battershall.) 

Suceus entericus has been said to change cane-sugar 
into grape-sugar and by a fermentative action to convert 
cane-sugar into lactic acid, and this again into butyric 
acid, with the evolution of carbonic acid and free hydro- 
gen. (Foster.) 



14 INFANT-FEEDING. 

Lgevulose is isomeric with dextrose, but it turns the 
plane of a ra}' of pohirized light to the left; it is non- 
erj^stallizable and ferments with difficulty. (Landois and 
Sterling.) 

Lactose, when isolated, is incapable of direct alcoholic 
fermentation, but milk itself may be fermented. Lactose, 
however, is directly capable of undergoing lactic and 
butyric fermentation. (Foster.) 

The theory — which a few years ago was accepted — 
that carbohydrates, to be absorbed, must be in the form of 
glucose is now known to be wrong. 

Lactose and maltose are absorbed without change, 
and probably some of the dextrins. (Roberts.) 

Lactose is a readily-soluble and diffusible body, and, 
by virtue of these properties, does not require to undergo 
change within the alimentary canal to be rendered fit for 
absorption. (Pavy.) 



CHAPTEE V. 

Anothek Peopeety of Gasteic Juice. 

Anothee property of gastric juice in infants is the 
transformation of albumin in the following manner: (1) 
albumose; (2) then peptone; (3) and lastly syntonin. It is 
thus apparent that^ although the infantile stomach plays 
a subordinate role as a nourishing organ, it cannot be de- 
nied that fluid substances — like water, a solution of salt, 
and solution of sugar — are absorbed, and in a lesser degree 
also albumin. The relative size and capacity of the stom- 
ach prevent the function from being as thoroughly de- 
veloped as in the adult. 

Length of Intestine. 

The relative length of the intestine in nurslings is 
larger than in adults; so that the length is six times as 
great as the length of its body. Forster believes that is 
one reason why nurslings receive more nourishment from 
milk than adults. The small intestine develops during 
the first two months of life more than the large intestine, 
and after the second month the reverse is true. The 
duodenum remains relatively the longest until the end of 
the fourth month. The transverse colon is the widest 
and most elastic portion of the large intestine. The con- 
tinuation of the large intestine in infants into the rec- 
tum is indicated by a narrowing at this point. 

The relative length of the large to .the small intestine 
is stated by Frolowsky to be in the newborn, 1 to 6; in 
nurslings, 1 to 5; in adults, 1 to 4. 

(15) 



16 JNFANT-FEP]DING. 

FOKMATJON OF (tAS IN THE INTESTINE. 

When we consider the lesser development of the 
muscles of the intestine, we can readily understand that 
peristaltic movements are more irregular and less forcible, 
and the muscles possess less tone; for this reason there 
is a larger amount of gas contained in the intestine, which 
constantly distends it. Thus it is apparent why the abdo- 
men always appears larger in the infant in proportion to 
the other parts of the body. 

Action of Intestinal Muscles. 

The action of the intestinal muscles is chieliy to trans- 
port the food by a series of peristaltic movements. Parts 
of the intestine are active, while others remain passive. 
Heubner maintains that post-mortem examinations never 
show all parts of the intestine in the same condition, 

owing to the irregularity of the muscular movement. 

* 

Development of Glandular System. 

The development of the glandular system in infants 
is very poor, whereas the lymphoid tissues, follicles, are 
comparatively luell developed. 

Lieberkiihn^s glands are -fewer in number than in 
adults, whereas the Brunner glands in the duodenum are 
numerous and well developed. 

The Secretory and Absorbing Power of the 
Epithelium and the Glands. 

Heubner maintains that the secretion takes place 
from cells, located in the small intestine, which are 
scatter-ed about and few in number, whereas in the large 
intestine they are far more numerous. 



ABSOKPTION OF FAT. 



17 



Absoeptioj^ of Fat. 

The absorption of fat takes place through the in- 
testinal epithelium in the duodenum and jejunum. This 
absorption of fat takes place from the epithelium lying 
on the superficial surface, whereby, also, the glands par- 
ticipate. This absorption of fat, according to the histo- 
logical investigations of Baginsky, takes place in the con- 
nective-tissue bodies of the mucous membrane of the in- 
fantile intestine, in which are located lymphatic vessels 
connected with the larger lymph-channels of the intestine, 
which is the real absorbing system of the intestinal wall. 
Thus it is apparent that the power of absorption in nurs- 
lings is better developed and functionates better than in 
adults. The physiological and chemical functions are far 
less developed in infants than in adults becaifse the in- 
testinal glands are relatively less developed. ' 



CHAPTER VI. 

Liver in Nurslings. 

The liyer in niTrslings is relatively larger than in 
adults. 

Bile. 

The quantity of bile in the gall-bladder is very small. 
It is of a golden-yellow color^ and has a nentral reaction. 
Its specific gravity varies from 1.014 to 1.053. Accord- 
ing to Baginsky, the bile in nurslings contains organic 
salts, — cholesterin and lecithin, — fat, and various acids 
in lesser proportion than in adults. Baginsky was able to 
demonstrate the presence of glycocolic acid. Thus it is 
apparent that the presence of a much lesser quantity of 
the bile-acids in the infant is a beneficial physiological 
condition. It is a well-known fact that these acids inhibit 
the digestive action of the pepsin, as well as the pan- 
creatic juice. Another point is that the absence of a bile- 
acid prevents the assimilation of large quantities of fat, 
as it is impossible to split up the fat into fatty acid and 
glycerin. Thus, fermentative processes are much more 
frequent in nurslings and appear with greater intensity 
than in the adult, because of the absence of the biliary 
acids. The amylacea and all substances containing flour 
are — owing to the above-described condition of the pan- 
creatic juice and the bile — not fit substances to give the 
infant, especially during its first three months of life, al- 
though very small quantities can be digested, and after 
the fourth month are not only digested, but absorbed. 
Baginsky and Sommerfeld found large quantities of mucin 
in the bile. 

(18) 



UJ^OEGANIZED FERMENTS. 



19 



Unoeganized Ferments. 

Table Showing the Unorganized Ferments Present in the 
Body and Their Actions. 



Fluid or Tjssues. 


Ferment. 


Actions. 


Saliva. 


1. Ptyalin. 


Converts starch chiefly 
into maltose. 


Gastric juice. 


1. Pepsin. 

2. Milk-curdling. 

3. Lactic-acid fer- 

ment. 

4. Fat-splitting. 


Converts proteids into 
peptones in an acid me- 
dium, certain by-prod- 
ucts being formed. 

Curdles casein of milk. 

Splits up milk-sugar into 
lactic acid. 

Splits up fats into glyc- 
erin and fatty acids. 


Paucreatic juice. 


1. Diastasic, or 

amylopsin. 

2. Trypsin. 

3. Emulsive (?). 

4. Fat-splitting, or 

steapsin. 

5. Milk-curdling. 


Converts starch chiefly 
into maltose. 

Changes proteids into pep- 
tones in an alkaline 
medium, certain by- 
products being formed. 

Emulsifies fats. 

Splits fats into glycerin 
and fatty acids. 

Curdles casein of milk. 


Intestinal juice. 


1. Diastasic. 

2. Proteolytic. 

3. Invertin. 

4. ]Milk-curdling. 


Does not form maltose, 
but maltose is changed 
into glucose. 

Fibrin into peptone (?). 

Changes cane-sugar into 
grape-sugar. 

In small intestine ( ? ) . 


Blood. 

Chyle. 

Liver (?). 

Milk. 

Most tissues. 


• 
Diastasic ferments. 




Muscle. 
Urine. 


Pepsin and other fer- 
ments. 




Blood. 


Fibrin-forming fer- 
ment. 





20 INFANT-FEEDIFG. 

The unorganized ferments seem to be nitrogenous 
bodies; their exact composition is unknown, and it is 
doubtful if they have ever been obtained perfectly pure. 
(Landois and Sterling.) 

Organized Ferments. 

Yeast is the type of the living, or organized, fer- 
ments. 

Other living ferments, schizomycetes, seem to be 
produced from the numerous fungi introduced into the 
intestinal canal with the food and drink. (Landois and 
Sterling.) 

The action of these organized ferments is now as- 
cribed to certain minute microscopic organisms; when the 
result is the production of some useful body the change 
is termed "fermentation," and "putrefaction'^ when the 
products are useless and offensive. 

Briefly stated, a liquid free from ferment-organisms 
or their germs does not undergo fermentation. (Jago.) 

The lactic fermentation and putrid or butyric fer- 
mentation of milk are both due to mysteriously-minute 
bacteroid bodies. (Blyth.) 

The fungi which occur everywhere in the atmosphere 
are the cause of the spontaneous acidification and subse- 
quent coagulation of milk. (Landois and Sterling.) 

The fermentation of carbohydrates, fats, and proteids 
is believed to be caused by these micro-organisms. 

Each particular organism has its special product of 
fermentation. (Jago.) 

Htdrolytic Agents. 
These bodies include oxalic and dilute hydrochloric 
and sulphuric acids. 



ABSOEPTION. 21 

Commencing with sohible starch, tliese acids possess 
the power of converting the body first into dextrin and 
maltose, and then into glucose. 

The acid hydrolytics also transform cane-sugar into 
glucose. 

There is another most important group of hydrolyzing 
agents; these consist of certain soluble bodies of organic 
origin, and among them may be mentioned human saliva, 
filtered aqueous infusion of yeast, flour, bran, and malt. 

The following names have been given to active prin- 
ciples of these hydrolytics: — 

Name of Hydrolyzing 
Substance. Constituent. 

Human saliva. Ptyalin. 

Yeast. Zymase, or invertin. 

Flour and bran, especially Cerealin. 

the latter. 
Malt. Diastase. (Jago.) 

AbSORPTIOIst. 

As most substances in the state in which they are 
used for food are either insoluble or diffuse but imper- 
fectly through membranes, the complicated digestive proc- 
esses render these substances soluble and diffusible, and 
thus fit them for absorption; most of the fats are emul- 
sionized. The mucous membrane of the intestinal tract 
from the cardiac orifice of the stomach to the anus is 
adapted for absorption. In the stomach, watery solutions 
of salts, grape-sugar, maltose, peptone, and poisons, espe- 
cially alcoholic solutions of poisons, are absorbed. The 
empty stomach absorbs more rapidly than one filled with 
food. Gastric catarrh delays absorption. The greatest 
area of absorption is undoubtedly the small intestine. 
(Landois and Sterling.) 



22 INFANT-FEEDING. 

Table of the jNIore Important Carbohydrates and 
Their Formul.ts. 

Cellulose CcHiqOs. 

Starch CJI.oO, or nlC^HioOg). 

Dextrin C.HioO^. 

Maltose Ci,H,,On or C^.H^^O,, + H,0. 

Dextrose (glucose, grape-sugar) C,jHi206 or C,., + Hi.H-O. 

Sucrose (saccharose, cane-sugar) CioH^oOn. 

Lsevulose CgHioOc. 

Invert-sugar CbHisO,;. 

Lactose (milk-sugar) C12H2.O11 or CiaHooOn -|- H2O. 

The sugars are classified into three groups, as given below, 
with their important members: — 

(A) Saccharoids (non-fermentable sugars) : — 

Mannite (from manna) CeHi^Oo- 

Dulcite C^H.^Oe. 

{B) Glucoses: — 

Dextrose (grape-sugar, starch-sugar) CoHiaOg + Aq. 

Lsevulose (honey) CeHiaOg. 

[G) Saccharoses: — 

Sucrose (cane-sugar) Ci.HaoOn + Aq. 

Maltose (malt-sugar) Ci.HoaOn + Aq. 

Lactose (milk-sugar) CjvHsoOn + Aq. 

Cellulose. 

Cellulose acts mainly as a sort of connective tissue 
constituting the frame-work of vegetable organisms. 

Enzymes. 

The enzymes^ hydrolytic or organic ferments^ act only 
in the presence of water; they are most active between 
30° and 35° C, and are destroyed by boiling. (Landois 
and Sterling.) 



soluble starch. 23 

Hydrolysis. 

The changes which carbohydrates undergo have been 
called by the general name of hydrolysis. (Jago.) 

Hydrolysis^ when affected by diastase or its con- 
geners, is termed diastasic action, or .diastasis. 

The ultimate jorodncts of diastasis of starch are sugars 
of various kinds; the process of conversion is frequently 
termed the saccharification of starch. 

Soluble Starch. 

Eesearches of Brown, Heron, and others make it 
probable that the formula of starch is more complex than 
usually expressed by CgH-ioOg, and the formula n(CeHio05) 
is now used, n expressing the unknowm. 

Soluble starch is expressed by the formula, 

n(C,,H,oO,o). 

Starch is soluble in cold water, and cannot be dis- 
solved by any known liquid without change, it having a 
definite organic structure, an outer envelope of cellulose 
inclosing the starch proper (amylose, or granulose). 

The cellulose envelopes may be ruptured by mechan- 
ical means or by boiling in water; in the latter case the 
containing cellulose bursts, from the interior particles 
swelling, and the amylose dissolves in the water, forming 
a viscous liquid (gelatinization). 

A solution of starch (soluble starch) is colorless, odor- 
less, and tasteless, but is colored an intense blue by the 
addition of iodine in extremely small quantities. (Jago.) 

Dextrin is very soluble in water; it can be prepared 
from starch by action of heat maintained at a tempera- 
ture of about 150° C. 

Starch, boiled with dilute sulphuric acid, will be con- 



24 INFANT-FEEDING. 

verted into dextrin and maltose^ and by continued boiling 
most of the dextrin and maltose is transformed into glu- 
cose (dextrose). 

Action of Malt-diastase. 

The action of malt-diastase on a solution of starch 
in water at temperatures from 15° C. to about 70° C. more 
or less rapidly hydrolyzes the starch into a mixture of dex- 
trin and maltose. The longer the operation is continued, 
the higher is the proportion of nlaltose produced; but 
even prolonged boiling does not result in any further 
hydrolysis of the maltose into glucose. 

Unlike the acids, malt-diastase is incapable of con- 
verting starch further than into dextrin and maltose. 
(Jago.) 

Brown and Heron's results lead to the opinion that 
there are several dextrins. And these dextrins are di- 
vided into two groups: erythrodextrins, those first forms; 
and achroodextrins (reducing dextrins). They also think 
that there is an intermediate body between dextrin and 
maltose which they call maltodextrin. 

According to Musculus and Gruber, erythrodextrin 
is a mixture of dextrin and soluble starch. 

Dextrin does not undergo alcoholic fermentation: 
but, after dextrose is formed from it, the dextrose is 
capable of directly undergoing vinous fermentation. (Fos- 
ter, Battershall.) 



CHAPTER VII. 



Fat. 



Fat contained in milk is no simple compound. It 
consists of at least nine compounds. More fat is found in 
colostrum^ in evening milk, and in upper layers of pail or 
bowl of milk. Its averag-^ percentage is 4.3 per cent.: a 
great deal more than in human milk. For this reason 
Jacobi° has always taught that "it is better to reduce the 
fat to be given to infants than to increase it." 

The deficiency of butter does, however, seriously im- 
pair the nutritive value of the milk. 

When there is not enough butter in the milk the 
casein present is digested with more difficulty, and the re- 
sult is the same as if the casein were in excess. 

The plastic (building) materials of food cannot be 
converted into the tissues of the body without the pres- 
ence of fat. Fat seems to be essential to the formation 
of new cells, whose nucleoli always contain fat, and there 
is more in young and rapidly-growing tissues than in those 
whose growth has been slackened by maturity. From this 
is evident the immense importance of fat in the nutrition 
of the rapidly-growing infant-body. 

Sugar. 

The effects of the deficiency of sugar will be partly 
the same as when butter is deficient, for the reason that 



^ A. Jacobi, "Intestinal Diseases of Infancy and Childhood,' 
page 87. 

(25) 



26 INFANT-FEEDING. 

sugar partly supplies the place of butter and partly is con- 
verted into fat. 

Other substances that result from the decomposition 
of sugar are of importance in many ways. Lactic acid is 
formed in the stomach, helps to give acidity to the gastric 
juice, and thus assists in the digestion of casein. 

Milk in which sugar is deficient frequently becomes 
a source of constipation in the child. (Jacobi.) 



Carbohydkates. 

This name is given to a class of compounds contain- 
ing six, or some multiple of six, atoms of carbon united 
with hydrogen and oxygen, the latter two in the same 
proportion as in water, HoO; for illustration, the carbo- 
hydrate, starch, is expressed by (C6Hio05)n (simplest for- 
mula). 

Hydeocarbons. 

Numerous compounds of carbon with hydrogen are 
classed under the general name of hydrocarbons; the ge- 
neric formula CnH^n -}- 2 is applied to such hydrocar- 
bons as petroleum, marsh-gas, and oils formed by the dry 
distillation of coal, wood, etc. (turpentine, etc.). 



Fats. 

In chemical constitution fats consist of the ethers 
of the higher fatty acids. 

Butyrin, or butter-fat, has the formula CJir,{CJi^02):i. 

Lard contains palmitin [C3H5(CigH3i02)3] and stearin 
[^3115(018113502)3]. 



FATS. 27 

Castor-oil contains ricinolein [03115(018113303)3] and 
palmitin (as above). 

The constitution of many fats and fixed oils is unde- 
termined. 

Another source of fat is its formation from albu- 
minous bodies. (Landois and Sterling.) 

While nitrogenous matter is mainl}- devoted to tis- 
sue-formation, the non-nitrogenous alimentary principles 
— the fats and the carbohydrates — supj^ly the source of 
power, — are appropriated to force-productions. 

The termi "hydrocarbons" has been applied by many 
writers to fats. 

The fats are a class by themselves. The hydrocar- 
bons are marsh-gas, benzin and its homologues, and re- 
semble the fats in many ways, but exhibit decided pecul- 
iarities, which mark them as a distinct group. 

The fats have the general formula of OioHigO. 

Fats are easily oxidized, yielding heat chiefly, and be- 
long, therefore, to the calorifacient group. 

There is every reason to believe, however, that fat is 
essential to tissue-development, as it seems to be in- 
trinsically mixed up with nitrogenized matter in the ani- 
mal tissues. 

Though fats cannot, per se, supply what is required 
for tissue-development, they, nevertheless, take part in 
the process. (Pavy.) 

Fat is absorbed in the form of an emulsion produced 
by the action of the bile and pancreatic juice; the villi 
of the small intestine are the chief absorbents, but the 
epithelium of the stomach and that of the large intestine 
also take a part. (Landois and Sterling.) 

The fats and the carbohydrates seem to be quite 
closely allied. 



28 INFANT-FEEDING. 

Part of the fat of the body is derived directly from 
the fat of the food^ and it is absorbed and deposited in 
the tissues. 

According to V. Voit, no fat is formed in the body 
directly from carbohydrates. 

Lawes and Gilbert, Heiden and V. Wolff arrived at 
the conclusion that the carbohydrates absorbed are di- 
rectly concerned in the formation of fats. We must as- 
sume that the carbohydrates are consumed or oxidized in 
the body and that thereby a non-nitrogenous body derived 
from the proteids is prevented from being burned up, and 
that it is changed into fat and stored up as such, 'No 
doubt, fat is formed indirectly in the blood in this way. 
(Landois and Sterling.) 

The balance of evidence seems to be in favor of the 
view that carbohydrates may be in some way directly con- 
verted into fat. 

The characteristic feature of proteid food is that it 
increases to oxidative, metabolic activity of the tissues, 
leading to a rapid consumption, not only of itself, but 
of non-nitrogenous food as well. 

One value of fats and carbohydrates lies in their 
being sources of energy, more than three-quarters of the 
normal income of potential energy coming from them, and 
they are ultimate sources of muscular energy as well as of 
heat; but their great characteristic is that they do not, like 
proteid food, excite the metabolic activity of the body, and 
therefore, instead of giving rise to bodies demanding im- 
mediate excretion from the system, can deposit their 
metabolic products as apparently little-altered, but in 
reality greatly-changed, fat. (Foster.) 



salts and water. 29 

Salts. 

The several saline matters, including the extractives 
of animal and vegetable food, are no less essential ele- 
ments of a diet than proteids, fats, or carbohydrates; by 
reason of their regulating the energy of foodstuffs, more 
strictly called, they are necessary to life; the body in their 
absence fails to carry out its usual metabolism, and dis- 
ease, if not death, follows. 

The salts must have important functions in directing 
the metabolism of the body. The striking distribution of 
them in the tissues, the preponderance of sodium and 
chlorides in blood-serum and of potassium and phosphates 
in the red corpuscles, must have some meaning, though 
we are in the dark concerning it. 



Salts and Water. 

The element phosphorus seems no less important 
than carbon or nitrogen; the element sulphur, again, is 
only second to phosphorus, and is a constituent of nearly 
all proteids. 

We know that the various saline matters are essen- 
tial to health; that when they are not present in proper 
proportions nutrition is affected; that the properties and 
reaction of various proteid substances are closely de- 
pendent on the presence of certain salts; but beyond this 
we know very little. 

Lastly, water has an effect on metabolism, as shown 
by the fact that, when the water of a diet is increased, 
the urea is augmented to an extent beyond that which can 
be explained by the increase of fluid augmenting the facili- 
ties of mere excretion. (Foster.) 



30 infant-feeding. 

Albuminous, or Proteid, Substances. 

The proteids form a large group of closely-related 
substances, all of which are, perhaps, modifications of the 
same bod}^ The infant manufactures most of the pro- 
teids of its ever-growing body from the casein of milk. 
Their chemical constitution is quite unknown. Some are 
soluble, others insoluble in water. The most important 
nitrogenized principles used as food are musculin, albu- 
min, casein, fibrin, gelatin, and gluten. The product of 
the digestion of such principles in the stomach was called, 
by Mialhe, albuminose; afterward, by Lehmann, peptones. 
This change renders them not easily coagulable and en- 
dosmotic, so that they pass through membranes with 
facility and are readily assimilated after their absorption. 
(FlintO 

Mtrogenous alimentary matter may be said to serve 
principally for the development and renovation of the 
living tissues. 

As to the production of a fat as a result of the 
splitting up of nitrogenous matter, it is highly probable 
that such production takes place, but anything in the 
nature of proof of this is wanting. 

The nitrogenous compounds are mainly ^'histo- 
genetic,^^ or tissue-forming, materials, but, by the separa- 
tion of urea which occurs in their metamorphosis in the 
animal system, an hyclrocarbonaceous compound is left, 
which may be appropriated to heat-production. (Pavy.) 

The nitrogenous bodies of milk are not thoroughly 
understood, and are too frequently classed under one 
head: proteids. 

For about five days after calving colostrum is se- 
creted by the mammary glands. This colostrum is poor 



PEOTEIDS. 31 

in fat and sugar, but ricli in proteids, which vary between 
15 and 30 per cent. These proteid bodies are not well 
understood, but albumin is about two-thirds of the total 
quantity. Casein is also present. Colostrum is curdled 
by rennet, but not as easily as milk, and it is interesting 
to note here that, for commercial purposes, the stomach 
of a calf under four days old is practically worthless for 
furnishing rennet. It is well known that large quantities 
of albumin are absorbed without peptonization; so it 
would be seen that Nature intended to furnish a very 
digestible food for the first few days of life. By the fifth 
or sixth day normal milk is secreted, the change from 
colostrum to milk being gradual, the quantity of albumin 
decreasing until in the normal milk it runs about 0.4 per 
cent. When the secretion ceases to coagulate on boiling, 
it is considered milk. 



Proteids. 

The division of the various component parts of milk 
by Baginsky into fat, carbohydrate, albumin, casein, salts, 
and water gives a clearer insight into the vital necessities 
of a growing infant. We have adopted this division from 
a clinical stand-point, because frequently a chemical re- 
port of an examination of breast-milk will show "deficient 
proteids,^^ and hardly convey to the unskilled which vital 
element is lacking. If, however, deficient albumin and 
casein were noted, instead of combining the two as one 
element and calling them proteids, then raw albumin, 
as the white of egg or yolk of egg, would suggest them- 
selves to remedy the element found wanting. I shall. 
therefore, speak of "deficient albuminoids^^ and "defi- 
ciency in casein'^ rather than combine these elements 



o2 INFANT-FEEDING. 

undor the one heading of proteids, which is now being 
used by so many text-books. 

A Clinical Method foe tlie Estimation of 
Breast-milk Proteids.^ 

"Two ^milk-burettes/ each containing- 5 cubic centi- 
metres of milk, are subjected to a temperature warm 
enough rapidly to sour the milk, and are allowed to re- 
main in this warmth until a distinct precipitation can be 
seen. The burettes are then cooled in water, the milk- 
serum is Yvithdrawn into the graduated tubes, 10 cubic 
centimetres of Esbach's solution (picric acid, 5 grammes; 



Fig. 8. — Woodward's Burette for Estimating Proteids. 

citric acid, 10 grammes; w^ater, 500 cubic centimetres) 
are added, the tubes are shaken, and centrifugated. until 
constant reading, and the resulting precipitate is read. 
This reading expresses in percentage the amount of total 
proteids in the milk. 

"Such is a bare statement of the method. I will 
briefly take up the various steps in detail. The ^milk- 
burettes' are made of about 10 cubic centimetres' capacity, 
and have a glass pinch-cock or valve and a narrow exit- 
tube about one inch long (Fig. 8). I have tried various 
forms of burettes and separating funnels, and find, this 



^ Reprinted in large part from George Woodward's article in 
the Philadelphia Medical Journal, May 21, 1898. 



LIME-SALTS IX COWS' MILK. 33 

the most satisfactory. A temperature of from 95° F. to 
100° F, is the most rapidly effectiye to produce fermen- 
tation. This I have conveniently obtained by placing the 
tubes in a burette-stand and the stand in contact with a 
radiator. The time required to obtain a distinct precipi- 
tation of casein is from eighteen to twenty-four hours. 
At the end of this time the milk has distinctly separated 
into an upper layer of viscid yellow fat; a lower layer 
of fluid milk, quite opaque above, almost translucent be- 
low; and, clinging to the sides of the tube, and especially 
at the bottom, a granular precipitate. The cooling of the 
milk increases the viscidity of the fat and facilitates its 
separation from the milk-serum. The milk-serum is re- 
ceived into 15-cubic-centimetre graduated tubes, the solu- 
tion of picric and citric acids added up to the 15-cubic- 
centimetre mark, the mixture stirred with a glass rod and 
placed in the hand-centrifuge. The amount of centrifuga- 
tion required is in direct proportion to the care used in 
separating the fat. If fermentation be watched and the 
separation be made as soon as the casein-precipitate is dis- 
tinctly present, the centrifugation to a constant reading 
may be quickly accomplished.'' 

LiME-SALTS IX Cows' MiLK. 

Milk curdles under two entirely-distinct sets of con- 
ditions: (1) it curdles on addition of an acid and (2) it 
curdles under the influence of rennet (when the reaction 
of the milk is either neutral or slightly acid). The two 
varieties of curd which are obtained under these circum- 
stances may be denominated "acid curds'' and "rennet 
curds,^' respectively. Acid curds must inevitably be 
formed in the stomach after milk has been drunk, if the 



34 INFANT-FEEDING. 

gastric contents are allowed to become acid. Siicli curds 
(we are familiar with them in ordinary life in the form, 
for instance, of cream-cheese or sour milk) are probably 
not sufficiently firm to set up digestive disturbances. On 
the other hand, rennet curds (such as we are familiar 
with in the form of renneted milk and of ordinary cheese) 
may be extremely firm. It is, therefore, in all probability 
these rennet curds which set up the familiar infantile 
dyspepsia of bottle-fed children. If this is so, the facts 
elicited by Arthus and Pages would appear to be of domi- 
nating importance in the treatment of these dyspeptic 
conditions. In order to appreciate this correctly the fol- 
lowing facts must be attended to: (1) rennet-coagula- 
tion is delayed and curdling becomes less and less firm 
as an increasing proportion of the lime-salts of the milk 
becomes precipitated as insoluble salts (Arthus ami 
Pages); (2) addition of soluble lime-salts (uj) to a certain 
maximum) causes increased rapidity of rennet-coagula- 
tion, accompanied by increased firmness of clot (Arthus 
and Pages); (3) human milk contains 0.03 per cent, of 
lime (Bunge); (4) cows^ milk contains 0.17 per cent, of 
lime (Bunge). (Lancet.) 

Lime-water and Milk. 

Dr. Brunn^ finds the use of lime-water as an addi- 
tion to milk a frequent cause of constipation and conse- 
quent fissures of the anus in children. Any cause which 
produces diarrhoea, with following- constipation, wdll 
cause it. Constipation, proctitis, and severe pains on 
defecation are the results of a fissure. Hernia and mas- 



^ Hospitals-tidende, R. 3, B. 8, S. 1089; Medical and Surgical 
Eeporter, February 13, 1892, page 277. 



MILK-SUGAR. 35 

turbatioii are possible consequences. The condition may 
be long-lasting, although it is easily discovered when at- 
tention is called to it. He treats it by regulating the 
diet, cleanliness, irrigation of the rectum, and dilation 
of the sphincter ani, which is easily done. 

BiCAEBOXATE OF SODA IX MiLK. 

The addition of the bicarbonate of soda to milk for 
its preservation has hitherto been tolerated by the police, 
but the Council of Hygiene of the Seine has condemned 
the practice, as it is not free from danger. The trans- 
formation of the sugar of milk into lactic acid gives rise, 
in milk so adulterated, to a lactate of soda, which is 
purgative, and is thus a cause of diarrhoea in young 
children. Under these conditions the Council considers 
that the addition of the bicarbonate of soda to milk, 
which is an aliment of the first order and very often pre- 
scribed for invalids and children, should neither be 
authorized nor tolerated.^ 

Soda is also added to milk sometimes to delay the 
souring process. The prohibition of this chemical may be 
viewed in the light of a stultification when we consider 
the large amount of bicarbonate of soda that is used at 
the present day in one of the popular methods of feeding 
infants. I think it is no -less reprehensible on the part of 
the physician than it is on the part of the dairyman.^ 

MlLK-SUGAE. 

Process of Jfal-ing. — The milk is collected and al- 
lowed to stand for several hours in cooling vats; then it 



* Lancet (London), February 11, 1888. 

^ E. E. Briish, M.D., in the Journal of the American Medical 
Association, November 23, 1889. 



36 INFANT-FEEDING. 

is conveyed to a large tank, to be coagulated. Various 
substances are used to hasten the coagulation. According 
to Flint,^^ vinegar, cream of tartar, muriatic acid, and 
sour milk can be used to produce coagulation, but, of 
course, rennet is the most popular and most commonly 
used agent. This, as we all know, is the fourth stomach 
of the calf. The directions given for preparing rennet are 
as follow: "Care must be taken not to use too much water 
in cleaning; wiping lightly with a moistened cloth until 
it is clean is the better way. If then blown up like a blad- 
der and hung up and dried, it will retain its power for 
coagulating milk for years.'' Pieces of this rennet are 
steeped in warm water, and the solution from it is added 
to the milk and then the milk is raised to a temperature 
above 100° and kept at that until coagulation takes place. 
Then the whey is drawn off, and this whey is evaporated 
by boiling to one-fifteenth of its original mass. This is 
dipped out into a tub, where the sugar will crystallize in 
twenty-four to forty-eight hours. These crystals are 
known as "sand"; this sand is put into sacks, from which 
the water drains off. The sand is again boiled in water to 
a sufficient concentration, and the sugar is allowed to 
crystallize in sticks. It will thus be seen that many of 
the other crystallizable bodies contained in milk would be 
included in this crystallization, as well as the alkaloids or 
ptomaines. 

The use of milk-sugar has increased notably during 
the last few years, in the feeding of children, through the 
recommendations of Soxhlet and Eeubner. It is not gen- 
erally known, however, that under some circumstances the 



'Milk-cows and Dairy-farming.' 



MILK-SUGAR. 37 

milk-sugar of cheaper sorts may be contamihated by tlie 
j^resence of bacteria^ derived from the milk from which 
it is made. In repeated examinations the author has 
found a large number of bacteria, and among them those 
which lead to the formation of gas: a form particularly 
feared because of its power to decompose milk. If such 
milk-sugar be added to sterilized milk it quickly curdles 
it; if, also, a small quantity of such sugar be added to a 
sterile milk, and subjected to the usual sterilizing methods 
for twenty or even forty minutes it is not as certainly 
rendered free from germs as is the case with ordinary 
milk. Enough germs, however, are destroyed so that the 
milk will not spoil until the second or third day. With 
the Soxhlet method of preparing the milk it was found 
that a very impure milk-sugar could be used without 
harm, provided it was used up within twenty-four hours. 
It was quite another matter when, as the author found, 
certain vendors of sterilized milk added the powdered 
sugar after the sterilization process. Through the addi- 
tion of the impure milk-sugar, countless germs were in- 
troduced into the sterile milk, and, since the milk is only 
slightly warmed before feeding, they enter the alimentary 
canal of the child, where they may produce the very evils 
one has sought to avoid. Under such circumstances the 
use of the relatively-sterile beet- or cane- sugar is prefer- 
able. From this is derived the practical rule that cheap 
grades of milk-sugar should be avoided in the preparation 
of the food of infants, or at least that they should be used 
only before a careful sterilization of the milk. (H. Xeu- 
mann.^^) 



^^ Berliner klinisclie Wochenschrift ; American Medico-Sur- 
gical Bulletin. 



38 INFANT-FEEDING. 

Dr. E. E. Brush/- of Mount Vernon^ N. Y., says that 
one of the faults of physiological chemists is that they 
make no distinction between a substance existing in a 
natural condition and that substance eliminated and iso- 
lated by chemical means. Thus^ the sugar of milk of com- 
merce and the sugar of milk as it exists in that fluid are 
regarded by the chemists as one and the same thing. 
Hence, the physician has been led into the error of think- 
ing that as the sugar in milk is that designed by nature 
as the best saccharine nutrient, therefore the isolated 
sugar must fulfill the same function. This is not the 
truth. Sugar of milk in that fluid is all assimilated, and 
the milk-sugar of commerce, when added to baby food, is 
eliminated both by the kidneys and bowels. This I haA'c 
demonstrated by numerous experiments. I have never 
found sugar present in the urine or fgeces of babies fed at 
the breast, but in three cases of infants fed with mixtures 
containing commercial milk-sugar to the amount of 3 
ounces or more in twenty-four hours (as in Meig's mixt- 
ure) I have always found sugar in the urine and faeces 
demonstrated by Fehling's test. 

Impurities in Milk-sugar. — J. 0. Braithwaite^^ states 
that the new United States Pharmacopoeia methods of 
testing milk-sugar do not suffice, because they consider 
only the contents in grape-sugar and cane-sugar. He 
found in a great number of samples a disproportionately 
high residue of ash, which coagulates milk when the latter 
is heated to nearly the boiling-point. This is a serious 
defect, since milk-sugar serves now mainly as a material 
for preparing artificial food for infants. The author 



^- Journal of the American IMedical Association, July 5, 1890. 
'^ London Pharni. Journal, April 14, 1894. 



MILK-SUGAR. 39 

found the ashes^ in several samples, to consist chiefly of 
magnesium; he found lime in one sample; and concludes 
that, during the preparation of the sugar, magnesium 
carbonate and lime had been used for neutralizing the 
acid solution, and that, during crystallization, magnesium 
lactate had crystallized out with the milk-sugar. The 
author confirmed, by way of experiments, the well-known 
fact that many metallic and earthy salts coagulate milk, 
and that magnesium lactate does so also, even in milk- 
sugar to which 0.5 per cent, of the salt had been admixed. 
He proposes that the pharmacopoeias restrict the amount 
of ash from milk-sugar to 0.25 per cent, as a maximum. 

Bacteria in Milk-sugar. — Prof. Albert K. Leeds^* 
states that all the samples of pulverized milk-sugar coming 
from drug-stores which he had examined gave an abun- 
dant crop of bacteria when definite weights dissolved in 
sterilized water were submitted to ordinary gelatin- 
peptone culture; and the presence of bacteria as a com- 
mon impurity in lactose, to be looked for and avoided by 
the chemist and the druggist, was sufficiently demon- 
strated.^* 



"Journal of the American Chemical Society; Oil, Paint, and 
Drug Reporter, August 31, 1896. 



CHAPTER VIII. 

Bacterium Coli Commune (Escherich). 

Obtained by Emmerich (1885) from the blood, vari- 
ous organs, and the alvine discharges of cholera patients 
at Naples; by Weisser (1886) from normal and abnormal 
human faeces, from the air, and from putrefying infusions; 







Fig. 9. — Bacterium Coli Commune. 

by Escherich (1886) from the fseces of healthy children; 
since shown to be constantly present in the alvine dis- 
charges of healthy men, and probably of many of the 
lower animals. Eound by the writer in the blood and 
various organs of yellow-fever cadavers in Havana (1888 
and 1889). 
(40) 



BACTERIUM COLI COMMUNE. 41 

Numerous varieties have been cultivated by different 
bacteriologists, which vary in pathogenic power and to 
some extent in their growth in various culture-media; 
but the differences described are not sufficiently charac- 
teristic or constant to justify us in considering them as 
distinct species. 

Morphology. — Differs considerably in its morphology 
as obtained from different sources and in various culture- 
media. The typical form is that of short rods with 
rounded ends, from two to three microns in length and 
0.4 to 0.6 micron broad; but under certain circumstances 
the length does not exceed the breadth — about 0.5 micron 
— and it might be mistaken for a micrococcus; again the 
prevailing form in a culture is a short oval; filaments of 
five microns or more in length are often observed in cult- 
ures, associated with short rods or oval cells. The bacilli 
are frequently united in pairs. The presence of spores 
has not been demonstrated. In unfavorable culture- 
media the bacilli, in stained preparations, may present un- 
stained places, which are supposed by Escherich to be due 
to degenerative changes in the protoplasm. Under cer- 
tain circumstances some of the rods in a pure culture 
have been observed by Escherich to present spherical, 
unstained portions at one or both extremities, which 
closely^ resemble spores, but which he was not able to 
stain by the methods usually employed for staining spores, 
and which he is inclined to regard as "involution forms." 

The bacillus stains readily with the aniline colors 
usually employed by bacteriologists, but quickly parts 
with its color when treated with iodine solution — Gram's 
method — or with diluted alcohol. 

Biological Cliaracters. — An aerobic and facultative 
anaerobic, non-liquefying bacillus. Sometimes exhibits 



42 INFANT-FEEDING. 

independent movements, which are not very active. One 
rod of a pair, in a hanging-drop culture, may advance 
slowly with a to-and-fro movement, while the other fol- 
lows as if attached to it by an invisible band (Escherich). 
The writer's personal observations lead him to believe 
that, as a rule, this bacillus does not exhibit independent 
movements. Does not form spores. Grows in various 
culture-media at the room-temperature — more rapidly in 
the incubating oven. Grows in a decidedly-acid medium. 
In gelatin plates colonies are developed in from 
twenty-four to forty-eight hours, which vary considerably 
in their appearance according to their age, and in differ- 
ent cultures in the same medium. The deep colonies are 
usually spherical and at first are transparent, homogene- 
ous, and of a pale-straw or amber color by transmitted 
light; later they frequently have a dark-brown, opaque 
central portion surrounded by a more transparent periph- 
eral zone; or they may be coarsely granular and opaque; 
sometimes they have a long-oval or "whetstone" form. 
The superficial colonies differ still more in appearance; 
very young colonies by transmitted light often resemble 
little drops of water or fragments of broken glass; when 
they have sufficient space for their development they 
quickly increase in size, and may attain a diameter of 
three to four centimetres; the central portion is thickest, 
and is often marked by a spherical nucleus of a dark- 
brown color when the colony has started below the surface 
of the gelatin; the margins are thin and transparent, the 
thickness gradually increasing toward the centre, as does 
also the color, which by transmitted light varies from 
light-straw color or amber to a dark brown. The outlines 
of superficial colonies are more or less irregular, and the 
surface may bo marked by ridges, fissures, or concentric 



BACTERIUM COLI COMMUNE. 43 

rings, or may be granular. The writer has observed colo- 
nies resembling a rosette^, or a daisy with expanded petals. 
Escherich speaks of colonies which present star-shaped 
figures surrounded by concentric rings. 

In gelatin stick cultures the growth upon the surface 
is rather dry, and may be quite thin, extending over the 
entire surface of the gelatin, or it may be thicker, with 
irregular, leaf-like outlines and with superficial incrusta- 
tions or concentric annular markings. An abundant de- 
velopment occurs all along the line of puncture, which, 
in the deeper portion of the gelatin, is made up of more 
or less closely-crowded colonies; these are white by re- 
flected light, and of an amber or light-brown color by 
transmitted light; later they may become granular and 
opaque. Frequently a diffused cloudy appearance is ob- 
served near the surface of the gelatin, and under certain 
circumstances branching, moss-like tufts develop at in- 
tervals along the line of growth. One or more gas-bubbles 
may often be seen in recent stick cultures in gelatin. 

Upon nutrient agar and blood-serum, in the incu- 
bating oven, an abundant, soft, shining layer of a brown- 
ish-yellow color is developed. The growth upon potato 
differs considerably, according to the age of the potato. 
According to Escherich, upon old potatoes there may be 
no growth, or it may be scanty and of a wdiite color. In 
milk at 37° C, an acid reaction and coagulation of the 
casein are produced at the end of eight or ten days. In 
the absence of oxygen this bacillus is able to grow in solu- 
tions containing grape-sugar (Escherich). In bouillon it 
grows rapidly, producing a milky opacity of the culture- 
liquid. The thermal death-point of Emmerich's bacillus, 
and of the colon bacillus from fasces, was found by Weis- 
ser to be 60° C, the time of exposure being ten minutes. 



44 INFANT-FEEDING. 

The writer has obtained corresponding results. Weisser 
found that when the bacilli from a bouillon culture were 
dried upon thin glass covers they failed to grow after 
twenty-four hours. These results give confirmation to 
the view that the bacillus under consideration does not 
form spores. 

PatJiogenesis. — Comparatively small amounts of a 
pure culture of the colon bacillus injected into the circu- 
lation of a guinea-pig usually cause the death of the ani- 
mal in from one to three days^ and the bacillus is found 
in considerable numbers in its blood. But, when injected 
subcutaneously or into the peritoneal cavity of rabbits or 
guinea-pigs, a fatal termination depends largely on the 
quantity injected; and, although the bacillus may be ob- 
tained in cultures from the blood and the parenchyma of 
the various organs, it is not present in large numbers, and 
death appears to be due to toxaemia rather than to septi- 
csemia. Mice are not susceptible to infection by subcu- 
taneous injections. Small quantities injected underneath 
the skin of guinea-pigs usually produce a local abscess 
only; larger amounts — two to five cubic centimetres — fre- 
quently produce a fatal result, with symptoms and patho- 
logical appearances corresponding with those resulting 
from intravenous injection. These are fever, developed 
soon after the injection, diarrhoea, and symptoms of col- 
lapse appearing shortly before death. At the autopsy the 
liver and spleen appear normal, or nearly so; the kidneys 
are congested and may present scattered punctiform ec- 
chymoses (Weisser). According to-Escherich, the spleen is 
often somewhat enlarged. The small intestine is hyper- 
semic, especially in its upper portion, and the peritoneal 
layer presents a rosy color; the mucous membrane gives 
evidence of more or less intense catarrhal inflammation. 



BACILLUS "d" of BOOKER. 45 

and contains mncuS;, often slightly mixed with blood. In 
rabbits death occurs at a somewhat later date, and diar- 
rhoea is a common symptom. In dogs the subcutaneous 
injection of a considerable quantity of a pure culture may 
give rise to an extensive local abscess. 

Varieties. — Booker, in his extended studies relating 
to the bacteria present in the faeces of infants suffering 
from summer diarrhoea, has isolated seven varieties 
"which closely resemble bacterium coli commune in 
morphology and growth in agar, neutral gelatin, and po- 
tato, but by means of other tests a distinction can be 
made between them.^^ These are described as follows: — 



Bacillus "d" of Booker. 

"Found in two cases of cholera infantum and the 
predominating form in one serious case of catarrhal en- 
teritis. 

'^Morphology. — Eesembles bacterium coli commune. 

"Groiuth in Colonies. — Gelatin: Colonies grow luxuri- 
antly in gelatin, and thrive in acid and sugar gelatin 
equally as well as in neutral gelatin. In the latter the 
colonies closely resemble, but are not identical with, the 
bacterium coli commune. In acid gelatin they differ very 
much from bacterium coli commune. The colonies spread 
extensively, and are bluish white, with concentric rings. 
Slightly magnified, they have a large, uniform, yellow 
central zone surrounded by a border composed of per- 
pendicular threads plac'ed thickly together. Sometimes a 
series of these rings appear, with intervening yellow rings. 

"Agar: The colonies are round, spread out, and blue 
or bluish white. Slightly magnified, they have a pale- 
yellow color. 



46 INFANT-FEEDING. 

"Stab Cultures. — Gelatin: In sugar gelatin the sur- 
face growth has a nearly-colorless centre surrounded by a 
thick border, with an outer edge of fine, hair-like fringe; 
the growth along the line of inoculation is fine and deli- 
cate. In neutral gelatin the growth is not so luxuriant 
as on sugar gelatin; on the surface it is thick and white, 
with a delicate stalk in the depth. 

"Agar: Thick white surface growth with a well- 
developed stalk in the depth. 

'^'Potato: Luxuriant yellow, glistening, moist, and 
slightly-raised surface, with well-defined borders. 

."Action on Milk.- — Coagulated into a gelatinous coag- 
ulum in twenty-four hours at 38° C, and into a solid clot 
in two days. 

"Milk-Litmus Beaction. — Milk colored blue with lit- 
mus is changed to light pink in twenty-four hours at 
38° C. The pink color gradually fades, and by the second 
or third day is white or cream color, with a thin layer of 
pink on top. The pink color extends in a few days about 
one-half down the clot. 

"Temperature. — Grows best about 38° C. 

"Spores have not been observed. 

"Gas-pr eduction. — Gas bubbles are produced in milk; 
not observed on potato." 



OF Booker. 

"Found as the predominating form in two cases of 
dysentery, one of which was fatal and the other a mild 
case. 

"Morphology. — Eesembles bacterium coli commune. 

"Growth in Cohnies. — Gelatin: The colony growth 
varies considerably with slight difference in the gelatin. 



OF BOOKER. 47 

In 10-per-cent. neutral gelatin the colonies resemble 
those of bacterinm coli eommnne. On the second or third 
day, when the colonies have just broken through the sur- 
face and are spread out^ it is impossible to distinguish 
one variety from the other, but as the colonies grow older 
a difference can generally be recognized. In sugar and 
acid gelatin the colonies have a clear centre with white 
border. Slightly magnified, a uniform brown centre sur- 
rounded by a brown zone composed of fine, needle-like 
rays perpendicular to the border. After cultivating for a 
few generations on acid and sugar gelatin the colonies 
cease to develop, and either grow in very small colonies 
or do not grow at all. The activity is regained if culti- 
vated on neutral gelatin. 

^^Agar: Colonies are large, round, and have a mother- 
of-pearl appearance. Slightly magnified, a uniform yellow 
color. 

"Stab Cultures. — Agar: Luxuriant, nearly colorless 
surface growth, with well-developed stalk along the line 
of inoculation in the depth. 

"Potato: Golden-yellow, glistening, slightly-raised 
surface, with well-defined borders. 

"Action on Milh. — Milk becomes gelatinous in twenty- 
four hours at 38° C, and in a few days a solid coagulum 
is formed. Milk colored blue with litmus is reduced to 
white or cream color in twenty-four to forty-eight hours 
at 38° C, with a thin layer of pink at the top of the 
culture. The pink color gradually extends lower in the 
coagTilum. 

"Temperature.— ThviYes best at about 38° C. 

"Spores have not been observed. 

"Gas-production. — Occurs in milk, but not seen in po- 
tato cultures. 



48 INFANT-FEEDING. 

"'Relation to Gelatin. — Does not liquefy gelatin. 

"Besemhlaiice. — Eesembles bacterium coli commune 
and bacillus "d/^ differing from the former in the charac- 
ter of the colony growth on acid and sugar gelatin and in 
ceasing to develop in these media after several genera- 
tions. It differs from bacillus 'd' in this latter respect.^^ 

Bacillus "f"' op Bookee. 

"Found in one case of cholera infantum and one case 
of catarrhal enteritis. 

"Morpliologij. — Eesembles bacterium coli commune. 

^'Growth in Colonies. — Gelatin: It is difficult to dis- 
tinguish the colony growth from the bacterium coli com- 
mune. There is often a difference in the colonies planted 
at the same time and kept under similar conditions, .but 
it is not very marked nor always the same kind of differ- 
ence. The tendency to concentric rings is greater in this 
variety. The colonies develop somewhat better on neutral 
and sugar gelatin than on acid gelatin. 

"Agar: The colonies are large, round, and bluish 
white. Slightly magnified, a light-yellow color. 

'^Stah Cultures. — Gelatin: The culture is spread over 
the surface and has a mist-like appearance; in the depth 
along the line of inoculation is a delicate stalk. 

"Agar: Thick, luxuriant, white surface growth, with 
a well-developed stalk along the line of inoculation in the 
depth. 

"Potato: Bright-yellow, glistening, moist surface, 
with well-defined borders, and but slightly raised above 
the surrounding potato. 

'^ Action on Milk and Litmus Reaction. — Milk is coagu- 
lated into a solid clot in twenty-four hours at 38° C, and 



BACILLUS "f" of BOOKEK. 49 

in forty-eight hours is reduced to white or cream color 
with a thin pink layer on top. 

"Gas-produdion. — Gas-bubbles arise in milk cultures, 
but they have not been observed on potato cultures. 

'^ Temperature. — Grows better at 38° C. 

"Spores have not been observed. 

''Relation to Gelatin. — Does not liquefy gelatin. 

"Resemllance. — • It closely resembles bacterium coli 
commune and Brieger's bacillus in the character of its 
growth upon different media, but is readily distinguished 
from both, as is also Brieger's bacillus from the bacterium 
coli commune, by the following differential test recently 
made known by Dr. Mall: Yellow elastic tissue from the 
ligamentum nuchge of an ox is cut into fine bits and is 
placed in test-tubes containing water Avith 10-per-cent. 
bouillon and 1-per-cent. sugar, and sterilized from one 
and one-half to two hours at a time for three consecutive 
days. Into this is inoculated two species of bacteria, one 
of which is the bacterium under observation, the other a 
bacillus found in garden earth. The latter bacillus is 
anaerobic; grows in hydrogen, nitrogen, and ordinary 
illuminating gas; in the bottom of bouillon; in the depth, 
but not on the surface, of agar stab cultures, and not at 
all in gelatin stab cultures. It has a spore in one end, 
making a knob bacillus. Different species of bacteria — 
streptococcus Indicus, tetragenus, fcholera, swine plague, 
bacterium lactis aerogenes, bacterium coli commune, 
Brieger's bacillus, and a number of varieties of bacteria 
which I have isolated from the faeces — were inoculated 
with head bacillus into the above-described elastic-tissue 
tubes. The tubes inoculated with Brieger's bacillus de- 
velop a beautiful purple tint, w^hich started as a narrow- 
ring at the top of the culture, gradually extending down- 



50 INFANT-FEEDING. 

ward and deepening in color until the whole tube has a 
dark-purple color. This color-reaction began in five to 
fourteen days, and was constantly present in a large num- 
ber of tests. Tubes inoculated with bacillus ^f gave a 
much fainter purple color, which was longer in appearing 
and never became so dark as with Brieger's bacillus. 

"Tubes inoculated with the other species of bacteria 
above mentioned gave no color-change and remained simi- 
lar to control. Bacillus T also shows a slight difference 
from bacterium coli commune in coagulating milk and 
reducing litmus more rapidly, and appears to produce 
more active fermentation in milk. Like Brieger's bacillus, 
the gelatin colonies more frequently show a concentric 
arrangement than those of the bacterium coli commune." 

Bacillus "g" of Booker. 

"Found in one case of serious gastro-enteric catarrh. 
It was not in large quantity. 

'^Morphology and Biological Characters. — In mor- 
phology, character of growth on agar, gelatin, and potato, 
it resembles bacterium coli commune. 

^'Action on Milk and Litmus Beaction. — Milk is not 
coagulated, and milk colored blue with litmus is changed 
to pink in a few days, and holds this color. These charac- 
teristics distinguish it from the bacterium coli commune. 

'^ Gas-production. — Not observed in milk or potato 
cultures. 

^'Belation to Gelatin. — Does not liquefy gelatin." 

Bacillus "h" of Booker. 

"Found in one case of mild dysentery, not in large 
quantity. 



I 



OF BOOKER. 51 

"Morphology. — Eesembles bacterium coli commune. 

"Groiutli in Colonies. — Gelatin: In plain neutral gela- 
tin the colonies resemble those of bacterium coli com- 
mune. In sugar gelatin the colonies are white and spread 
extensively. Slightly magnified^ they have a rounds dark 
centre surrounded by a yellow^ loose zone with an outer 
white rim; later the whole colony has a uniform yellow 
color and is not compact. 

"Agar: Colonies are white^ round, and large. Slightly 
magnified, they are brownish yellow. 

"Stab Cultures. — N"othing characteristic in gelatin 
and agar. 

'"Potato culture is yellow, dry, and slightly raised, 
with well-defined borders. 

"Action on 21 ilk and Litmus Reaction. — Milk is coagu- 
lated into a solid clot in two days at 38° C. Milk colored 
blue with litmus is changed to pink in twenty-four hours. 

"Gas-production. — Occurs in milk; not observed on 
potato. 

"Relation to Gelatin. — Does not liquefy gelatin." 

Bacillus "k" of Bookee. 

"Found in two cases of cholera infantum and one of 
catarrhal enteritis. 

"Morphology. — Eesembles bacterium coli commune. 

"Groivth in Colonies. — Gelatin: In neutral gelatin the 
colonies cannot be distinguished from those of bacterium 
coli commune. In acid gelatin the colonies do not spread 
so extensively as those of bacterium coli commune, and 
they have a decided concentric arrangement: a wide white 
centre surrounded by a narrow, transparent blue ring; 
and outside of this a white border. Slightly magnified, 
the colonies have an irregular, yellowish-brown centre. 



52 INFANT-FEEDING. 

mottled over with dark spots and surrounded by a light- 
yellow ring bordered by a brownish-yellow wreath. 

"Agar: Colonies are large, round, and bluish white. 
Slightly magnified, a light-brownish-yellow color. 

"Stat Cultures. — Gelatin: In sugar gelatin the sur- 
face growth is extensive; nearly colorless; and has a 
rough, misty appearance. In the depth is a delicate 
growth. In plain neutral gelatin the surface growth is 
bluish white, thick, and not so extensively spread; the 
growth in the depth is also thicker. 

"Potato culture is moist, dirty-cream color, has raised 
surface and defined border. 

^^ Action on Milk. — Milk becomes gelatinous in twenty- 
four hours at 38° C, and a solid clot in two days. Milk 
colored blue with litmus is changed to pink in twenty-four 
hours, and reduced to white, with a pink layer on top, in 
two days.^^. 

Bacillus "n" of Booker. 

"Found in large quantity, but not the predominating 
form, in one case of chronic gastro-enteric catarrh (ex- 
tremely emaciated). 

'^Moiyliology. — Eesembles bacterium coli commune. 

"Growth in Colonies. — -Gelatin: In neutral gelatin the 
colonies are spread out and have a frosty, or ground-glass, 
appearance. The centre is blue and border white, but 
both have the ground-glass appearance. Slightly magni- 
fied, the central part is light yellow and the border brown, 
with a rough, furrowed surface. In acid gelatin the white 
border is wider and the surface is rougher. 

"Agar: Colonies are round, blue, or bluish white, and 
spread out. Under the microscope they have a light-yel- 
low color. 



BACTERIU:\I LACTIS AEROGENES. 53 

"Stah Cultures. — Grelatin: Has a rough, nearly color- 
less surface growth, and a thick stalk in the depth along 
the line of inoculation. 

"Agar: Thick white surface growth, with well-de- 
veloped stalk in the depth. 

^'Action on Milk and Litmus Reaction. — Milk remains 
liquid and milk colored hlue with litmus is changed to 
pink. 

^'Gas-production. — Not observed in milk or potato 
cultures. 

"Relation to Gelatin. — Does not liquefy gelatin. 

"Spores have not been noticed.'^^^ 

Bacterium Lactis Aeirogenes. 

Synonym. — Bacillus lactis aerogenes (Eseherich). 

Obtained by Eseherich (1886) from the contents of 
the small intestine of children and animals fed upon milk; 
in smaller numbers from the fgeees of milk-fed children, 
and in one instance from uncooked cows' milk. 

Morpliology. — Short rods with rounded ends, from 
1 to 2 microns in length and from 0.1 to 0.5 micron 
broad; short-oval and spherical forms are also frequently 
observed, and under certain circumstances longer rods — 
3 microns — may be developed; usually united in pairs, 
and occasionally in chains containing several elements. 
In some of the larger cells Eseherich has observed un- 
stained spaces, but was not able to obtain any evidence 
that these represent spores. 

This bacillus stains readily with the ordinary aniline 
colors, but does not retain its color when treated by 
Gram's method. 



'' Sternberg's "Manual of Bacteriology," 1892. 



54 



INFANT-FEEDING. 



Biological Characters. — An aerobic (facultative an- 
aerobic), non-liquefying, non-motile bacillus. Does not 
form spores. Grows in various culture-media at the room- 
temperature — more rapidly in the incubating oven. Upon 
gelatin plates, at the end of twenty-four hours, small, 
white colonies are developed. Upon the surface these 
form hemispherical, soft, shining masses which, examined 







» *' •» 

•^v/ 



Fig. 10. — Bacterium Lactis Aerogenes. 



under the microscope, are found to be homogeneous and 
opaque, with a whitish lustre by reflected light. The deep 
colonies are spherical and opaque, and attain a consider- 
able size. In gelatin stick cultures the growth resembles 
that of Friedlander's bacillus; i.e., an abundant growth 
along tlie line of puncture and a rounded mass upon the 
surface, forming a ''nail-shaped" growth. In old cult- 



BACTERIUM LACTIS AEROGENES. 55 

iires the upper part of the gelatin is sometimes clouded^ 
and numerous gas-bubbles may form in the gelatin. Upon 
the surface of nutrient agar an abundant, soft, white layer 
is developed. Upon old potatoes, in the incubating oven, 
at the end of twenty-four hours a yellowish-white layer, 
several millimetres thick, is developed, which is of paste- 
like consistence and contains about the periphery a con- 
siderable number of small gas-bubbles; this layer in- 
creases in dimensions, has an irregular outline, and lai*'ger 
and more numerous gas-bubbles are developed about the 
periphery, some the size of a pea; later the whole surface 
of the potato is covered with a creamy, semifluid mass 
filled with gas-bubbles. On young potatoes the develop- 
ment is different; a rather luxuriant, thick, white or pale- 
yellow layer is formed, which is tolerably dry and has 
irregular margins; the surface is smooth and shining, 
and a few minute gas-bubbles only are formed after sev- 
eral days. 

Patlwg&msis. — Injections of a considerable quantity 
of a pure culture into the circulation of rabbits and of 
guinea-pigs give rise to a fatal result within forty-eight 
hours. 

In his first publication relating to ^''the bacteria found 
in the dejecta of infants afflicted with summer diarrhoea,'' 
Booker has described a bacillus which he designates by 
the letter "b,'' which closely resembles bacillus lactis 
aerogenes and is probably identical with it. He says: — 

'^Summary of Bacillus '^h.' — Found nearly constantly 
in cholera infantum and catarrhal enteritis, and generally 
the predominating form. It appeared in larger quantities 
in the more serious cases. It was not found in the dysen- 
teric or healthy faeces. It resembles the description of the 
bacillus lactis aero^'enes, but the resemblance does not 



56 INFANT-FEEDING. 

appear sufficient to constitute an identity, and, in the ab- 
sence of a culture of the latter for comparison, it is con- 
sidered a distinct variety for the following reasons: Bacil- 
lus 'b' is nniformly larger, its ends are not so sharply 
rounded, and in all culture-media long, thick filaments 
are seen, and many of the bacilli have the protoplasm 
gathered in the centre, leaving the poles clear. There is 
some difference in their colony growth on gelatin, and in 
geiatin stick cultures bacillus 'b^ does not show the nail- 
form growth with marked end-swelling in the depth. In 
potato cultures the bacillus lactis aerogenes shows a differ- 
ence between old and new potatoes, while bacillus ^b' does 
not show any difference. 

"Bacillus ^b^ possesses decided pathogenic properties, 
which were shown both by hypodermic injections and 
feeding with milk cultures.^^ 



CHAPTEE IX. 

COLOSTKUM. 

Colostrum is found in the breast of a woman several 
hours after birth. It resembles milk, but is a much 
thinner fluid. It is always the forerunner of a healthy 
normal secretion of breast-milk, which usually appears on 
the third day after the birth of the infant. 

Colostrum is the earliest milk, very thin and watery 



o'^»P' 



9^6 







Colostrum- 
corpuscles 



Fig. 11. — From a Drop of Milk on the Third Day after Deliv- 
ery, kindly Furnished by Dr. H. L. Collyer, showing Co- 
lostrum-corpuscles. The specimen drawn by Dr. Julian W. 
Brandeis. (Zeiss Ocular 4, dd Lens.) 



in color, very rich in salts, with decided purgative proper- 
ties, saving all useless castor-oil, honey, and butter and 
all sugar-water, with which mothers and nurses take such 
delight in experimenting with. 

According to Baginsky, colostrum contains large 
quantities of serum-albumin, is also very rich in fat and 

(57) 



58 INFANT-FEEDING. 

colotjtrum-corpuscies^ and a large quantity of salts. The 
last t'wo ingredients are supposed to be the cause of the 
laxative action of the colostrum. 

Immunity by Breast-milk. 

It is a well-known fact, and one that has been 
brought out most prominently by Brieger and Ehrlich 
and Baginsky, that immunity can be conferred on a child 
by nursing the milk of its mother. This question has also 
been studied with reference to conferring immunity in 
infectious diseases, and H. Neumann has found that im- 
munity can be conveyed to an infant by the agency of 
breast-milk. 

The Two Mammary Glands. 

The two mammary glands of the same woman may 
yield somewhat different milk, as shown by Sourdat and 
later by Brunner. Also the different portions of milk 
from the same milking may have different compositions. 
The first portions are always poorer in fat (Parmentier, 
Peligot, and others). 

According to I'Heritier Vernois and Becquerel, the 
milk of blonds contains less casein than that of brunettes: 
a difference which Tolmatscheff could not substantiate. 
Women of weak constitutions yield a milk richer in solids, 
especially in casein, than women with strong constitu- 
tions. 

According to Yernois and Becquerel, the age of the 
woman has an effect on the composition of the milk, so 
that we find a greater quantity of proteids and fat in 
women 15 to 20 years old and a smaller quantity of sugar. 
The smallest quantity of proteids and the greatest quan- 
tity of sugar are found at 20 or from 25 to 30 years of 



59 

age. The milk with the first-born is riclier in water — 
with a proportionate diminution of the quantity of casein, 
sugar, and fat — than after several deliveries. The influ- 
ence of menstruation seems to slightly diminish the milk- 
sugar and to considerably increase the fat and casein. 

Witch's Milk. 

Witch's milk is the secretion of the mammary glands 
of newborn children of both sexes immediately after birth. 
This secretion has, from a qualitative stand-point, the 
same constitution as milk, but may show^ important dif- 
ferences and variations from a quantitative point of 
view. Schlossberger and Hauff, Gubler and Quevenne, 
and von Gesner have made analyses of this milk, and give 
the following results: 10.5-28 p. m. proteids. 8.2-14.6 p. m. 
fat, and 9-60 p. m. sugar. 

The newborn human infant almost constantly se- 
cretes a fluid in the mammae, and adult males have not 
only secreted milk, but that in abundance enough to 
suckle. Females, also, both human and animal, occasion- 
ally secrete milk without having been previously pregnant. 
With regard to the milk secreted by infants, there is some 
doubt about its real nature. Kollicker does not view^ it as 
a true milk, but considers its appearance connected with 
the formation of the mammary glands. 

Sinety, on the other hand, upon anatomical grounds 
considers it a true lacteal secretion. It probably is a sort 
of imperfect milk, loaded with leucocytes, and this is the 
more likely as Yollard^^ notices that it frequently ends 
in abscess. 



^® "Traite des Maladies des Enfants nouveau nes," third edi- 
tion, 1837, p. 717. 



60 INFANT-FEEDING. 

Schlossverger gives an imperfect quantitative anal- 
ysis of a sample of milk obtained by squeezing the breasts 
of a newborn infant^ a male. In the course of a f^w 
days about a drachm was obtained. The following was 
the result of the analysis: — 

Water 96.75 

Fat 0.82 

Ash 0.05 

Casein, sugar, and extractives 2.83 

Sugar-reaction strong. 

The most complete analysis we possess of such milk is 
by von G-esner: — 

Milk-fat 1.456 

Casein 0.557 

Albumin 0.490 

Milk-sugar 0.956 

Ash 0.826 

Water 95.705 

Total solids 4.295 

Joly and Filhol have recorded the case of an old 
lady^ 75 years of age^ who suckled successfully her grand- 
child. Similar instances have been recorded in dogs, and 
we fortunately possess one or two analyses which show 
that the fluid is certainly milk. Thus, Filhol and Joly 
give the following analysis of the milk derived from a 
bitch which had no connection with a male: — 

Specific gravity 1.069 

Total solids 29.00 

Fat 2.20 

Sugar 0.32 

Albumin ^ 23.20 

( 



MEN SUCKLING CHILDREN. 61 

The ash, on analysis, gave the following percentage: 

Chloride of sodium 65.10 

Chloride of potassium 3.88 

Calcic phosphate 27.75 

Sodie phosphate 1.40 

Sodic carbonate 1.87 

Traces of magnesia and other phosphates. 



Men Suckling Childeen. 

Men before now have sncklecl children. Humboldt 
relates the case of Francisco Lozano, whom he saw, and 
whose case he carefully investigated; and it appears estab- 
lished that this man did secrete from his breasts a nutri- 
ent fluid, on which his infant son lived for many months; 
it is said, indeed, a whole year. The curious in such mat- 
ters may consult the references given farther on.^"^ 



" 1. "Untersuchung der sogenannte Hexenmilch."' J. Schloss- 
berger, Annalen der Chemie und Pharmacie. B. 87, 1852. 2. Eobert 
Bishop of Cork: letter concerning a man avIio gave suck to a child. 
Phil. Trans., 1741, Xo. 461, page 813, etc. 



CHAPTEE X. 

Breast-milk. 

According to Pfeiffer^ human milk contains, several 
days after the birth of the baby, a large quantity of albu- 
min, salt, and a small quantity of fat. He also found 




Fig. 12. — This Illustration was Drawn by Dr. J. W. Brandeis 
from a Drop of Breast-milk Taken from a Wet-nurse Em- 
ployed in the Author's Family. It Represents an Elegant 
Emulsion of Evenly-Divided Fat-globules. Note the Reg- 
ularity of their Size. 

that, the longer the period of nursing, the smaller the 
quantitv of albumin, which, in the eleventh month, sinks 
(62) 



BEEAST-MILK. 63 

quite low. There is also a decrease in the quantity of salts, 
whereas the amount of sugar steadily increases. The fat 
varies constantly. According to Johannessen^ the quan- 
tity of albumin in the first six months is 1.192 per cent.; 
in the next six months 0.989 per cent.; and at the end 
of the year 0.907 per cent. 

Breast-milk varies according to the length of time 
that it remains in the breast, and also the length of the 
nursing period; so it has been shown that the first milk 
taken at the beginning of the nursing act is the poorest 
in nutrient value, whereas the last milk is richest in fat. 
The longer the milk remains in the glands of the breast, 
the more solid substances of the same will be absorbed: 
so that only a watery solution remains. If sucking is com- 
menced^ this stimulation soon changes the character of 
this watery milk, so that normal milk will soon be se- 
creted. Forster studied the chemical examination of the 
firsts middle, and the last portions of milk from a nursing 
woman^ with the following result: — 

In one hundred parts he found: — 

First Portion of the Nursing Act. 

Water 90.24 

Nitrogenous substances 1.13 

Fat . 1.70 

Sugar 5.56 

Ash . 0.46 

The quantity examined was 33.1 grammes. 

Second Portion {during the Nursing). 

Water 89.68 

Mtrogenous substances 0.94 

Fat 2.77 

Sugar 5.70 

Ash 0.32 

The quantity examined was 33.1 grammes. 



64 rNFANT-FEEDING. 

Third Portion {<Jrt the End of the Nursing Act). 

Water 87.50 

Nitrogenous substances 0.71 

Fat 4.51 

Sugar 5.10 

Ash 0.28 

The quantity examined was 37.3 grammes. 

From a study of the foregoing tables we find a de- 
crease of nitrogenous substances during the course of the 
nursing, that the fat constantly increases, and the milk- 
sugar remains constant. Thus, it is apparent that, in 
order to submit a specimen of hreast-milk to a chemical 
examination, it is necessary to stimulate the secretory 
functions of the mammary glands by putting the child 
to the breast at least two minutes; thus an even milk can 
be procured. If this rule is overlooked, then we will find 
variations in the chemical components of milk which 
might otherwise be entirely different. The most recent 
chemical analysis of breast-milk shows that in a hundred 
parts there are 

Solids 11.5 

Liquids 88.5 

Of the solid constituents there is 

Casein 1.2 to 1.03 

Albumin 0.5 

Fat 0.8 to 4.07 

Milk-sugar 6.0 to 7.03 

Ash 0.2 to 0.21 

The above is the chemical examination of a good 
average breast-milk. I have previously shown, however, 
that not only does the milk vary in different women, but 
it also varies in the same woman during one single nurs- 
ing act. 



BREAST-MILK. 65 

The albuminoids of milk consist of real casein^ lact- 
albumin, globulin, and opalisin. This latter body has only 
recently been discovered by A. Wroblewski, and more re- 
cently by Schlossmann. 

Phosphorus exists in milk as nuclein-phosphorus. 
Wittmaack has demonstrated the fact that the phosphorus 
in woman^s milk exists as an organic nitrogen compound 
in the casein. 

Lecithin contains a larger quantity of phosphorus in 
woman's milk than in cows' milk^ according to the exami- 
nation of Stolasa. 

The specific gravity of breast-milk varies from 1.026 
to 1.036. 

SPECIMEisT OF BREAST-MILK FOR CHEMICAL 
EXAMINATION^. 

After the third, possibly tlie fourth, day the average 
healthy woman secretes milk that gradually becomes nor- 
mal in quality and quantity, depending on her general 
condition. It is usual for an infant to lose some weight 
during its first week of life, owing to various physiological 
changes, added to which is, no doubt, the deficiency in 
the quality and quantity of its food. It is a safe plan, 
and one that I have always urged, if at all possible, to 
send a specimen of breast-milk to a chemist and sub- 
mit the same to a chemical analysis. In some women a 
specimen can be examined when the baby is one week old; 
in others it is better to wait until the end of two weeks. 
AYe then would have a proper working basis, and know 
just how much fat, carbohydrate (sugar), and albuminoids 
— including proteids — we are feeding; noting the weight 
of the child, its sleep, its digestion, color and frequency 
of its stools; we can easily see in one week how much the 



06 INFANT-FEEDTNC). 

iiiFaiit lias i^aiiu'd in wci^iht, aiul its goneral condition. 
To lake a specimen^ it is advisable to have all utensils 
absolutely clean; hence the following plan would be sug- 
gested: Boil an ordinary one- or two- ounce bottle in 
water, to which a piece of baking soda has been added, 
for about one-half hour. Then place the bottle in plain 
water and boil again for a half-hour. Then turn the 
bottle upside down, and allow it to drain and dry. In 
this manner we can completely sterilize the inside of the 
bottle, which is very vital to avoid contamination. 

Withdraw a sample of Ijreast-milk by taking a breast- 
pump. One of which has served the author very well is 
known as the Florence breast-pump, and has a glass 
mouth-piece. (See illustration, Fig. 15.) Another breast- 
pump is an English breast-pump, having a rubber bulb; 
compressing this bulb, we can suck about an ounce or 
more in from five to ten minutes. This milk is to be 
poured in the bottle, and well corked, and set in a re- 
frigerator, but not on the ice. Milk will keep for many 
hours in this way. My plan has been to inform the chem- 
ist the day previous to submitting the sample, so that it 
can be withdrawn from the breast early in the morning^ — 
at about 8 a.m. — and sent to the laboratory at once. The 
result of the analysis can be received on the evening of 
the same day or the following day in all instances. A 
point worth noting is that the very first milk — known as 
the foremilk — should not be used, but the infant should 
be allowed to suck at the breast for about two minutes 
before pumping the sample. After this the breast-pum]) 
should be applied for five minutes to procure the so-called 
middle milk for examination; then the infant can again 
be put to the breast to finish the so-called end of nursing 
or to suck the strippings. 



BEEAST-MILK. 



67 



1 




Pro- 








Human Milk. 


Fat. 


TEIDS. 


8UGAB 


Ash. 


Authority. 


Normal 3Tilks. 












Average . 


2.90 


3.07 


5.87 


0.16 


A. W. Blythe. 


xiverage ... 


3.68 


1.70 


7.11 


0.20 


Marchand. 


Average . . 


2.67 


3.92 


4.37 


0.14 


Vernols& Becquerel. 


Average . 


3.52 


2.01 


5.91 




Hammarsten. 


14 analyses from 












same woman 


2.53 


3.42 


4.82 


0.23 


Simon. 


Mean of 6, aged 












23-33 years 


3.82 


2.04 


5.93 


0.42 


H. Gerber. 


Average . 


3.55 


1.52 


6.50 


0.45 


Chevalier & Henry. 


From woman aged 












18 


3.20 


2.39 


6.83 


0.29 


J. Bell. 


From woman aged 












33 


2.99 


2.51 


6.51 


0.30 


J. Bell. 


4 days after deliv- 












eiy • 


4.30 


3.53 


4.11 


0.21 


Clemm. 


9 days after deliv- 












ery . 


3.53 


3.69 


4.30 


0.17 


Clemm. 


12 days after de- 












livery 


3.34 


2.91 


3.15 


0.19 


Clemm. 


Average of 84 












samples . 


4.13 


2.00 


6.94 


0.20 


Leeds. 


Average of 107 












samples . 


3.78 


2.09 


6.21 


0.31 


Konig. 



CHAPTER XI. 

Breast-feeding. 

During the first montli feed every two hours, but 
never ofteiier. Durmg the second month, every two and 
a half to three hours. 

Never disturb a chikl from its sleep to be nursed; 
so that the rule should be to leave the baby rest as long 
as it appears satisfied. This rule applies to healthy chil- 
dren only. In sickness special feeding rules are required. 
If the child thrives, gains in weight, then it is advisable 
in the interest of the mother and child to have an interval 
of from seven to eight hours at night; thus Bouchut ad- 
vises feeding between 10 and 11 at night and commencing 
the morning meal at 6 a.m. If the child is restless, then 
turn the child from side to side; in other words, changing 
its position and giving it 1 or 2 teaspoonfuls of boiled 
water will frequently satisfy it and prolong its sleep. 

Time for Feeding. 



From 

BlBTH 


At 
1 Month 


2 TO 4 


4 TO 6 


6 to 9 
Months Old. 


9 Months 


UNTIL. 1 


UNTIL 2 


Months 


Months 


UNTIL 


Month 


Months 


Old. 


Old. 


1 Year ■ 

OLD. 


Old. 


Old. 








6 A.M. 


6 A.M. 


6 A.M. 


6 A.M. 


6 A.M. 


6 A.M. 


8 A.M. 


9 A.M. 


9 A.M. 


9 A.M. 


9.30 to 10 A.M. 


10 A.M. 


10 A.M. 


11 A.M. 


12 Noon. 


12 Noon. 


1.30 to 2 P.M. 


2 P.M. 


12 Noon. 


1 P.M. 


3 p.m. 


3 p.m. 


5.30 to 6 P.M. 


6 P.M. 


2 P.M. 


3 P.M. 


6 P.M. 


6 P.M. 


9.30 to 10 P.M. 


]Op.m. 


4 P.M. 


5 P.M. 


9 P.M. 


9 P.M. 






6 P.M. 


7 P.M. 


12 Mid- 








8 P.M. 


9 P.M. 


nijjfht. 








10 P.M. 


11 P.M. 










12 Mid- 












night. 













1 



(68) 



BREAST-FEEDING. 69 

The first three or four days after birth require special 
feeding methods: — 

On the day of the birth, the exhaustion of the mother 
and presence of colostrum, besides the normal deficient 
quantity of food in the breast, demand large intervals of 
rest; thus for the first three days (unless the milk-supply 
is profuse) putting the infant to the breast once every six 
hours would be ample; if, however, the supply of milk is 
am^^le, then we can follow the table given above and nurse 
the infant every two hours, 

SUGGESTIONS FOR BREAST-FEEDING. 

The mother or wet-nurse should always sit upright, 
be it at night or during the day, while nursing the infant. 

Danger of Suffocation.— A. great many cases are on 
record where the mother or wet-nurse has fallen asleep 
while nursing, and smiothered the child. For this reason 
it is important that the infant should sleep in its own 
crib or bed, and should never sleep with its mother or 
nurse. 

Sliall am Infant Receive tut One or Both Breasts for 
One Meal? — This depends on the infant's appetite. Some 
infants appear satisfied after nursing from one breast, 
and will let the nipple go and fall asleep. Light tapping 
on the cheeks of the infant will awaken it, or the with- 
drawal of the nipple from the infant's mouth will fre- 
quently arouse the child to continue its nursing. If, how- 
ever, an infant will not renew its nursing, and still con- 
tinue to sleep, and if the infant has nursed steadily for 
ten minutes, then the sleep should not be disturbed. 

Length of Time for Nursing. — A good plan is to note 
the time Avhen the nursing act commences and stops. No 
infant should* nurse longer than 20 minutes, whereas fre- 



70 INFANT-FEEDING. 

(liuMilly 10 iiiiiuitcs or 15 minutes will suflice. If an in- 
fant nurses more than 20 minutes, say 30 or 4:0 minutes, 
then we may be sure that the breast-milk is deficient in 
quantity, and a specimen should at once be submitted for 
a ju'oper chemical examination. 

Mixed Feeding. 

When there is a deficiency in the quantity of breast- 
milk, but the quality is good, then it is advisable to feed 
the infant alternately with breast-milk and bottle-milk. 
At the same time, it is advisable to direct attention to the 
mother's general condition, and see if we cannot tone her 
up, and thus improve both quality and quantity of her 
milk. Frequently a subnormal or anaemic condition re- 
quires iron; in other cases a day's outing to the sea-shore 
or to the country, with moderate exercise, will stimulate 
and increase the flow of milk. It is well to try some 
galactagogues. Among them the author has found an 
albumin diet (meat, milk, and eggs) and a preparation 
known as nutrolactis in tablespoonful doses before meals to 
have acted very well in some cases. Grandin and Jarman, 
in their text-book on obstetrics, recommend the strong 
infusion of galega officinalis when the flow of milk is scant. 
This is to be ordered in tablespoonful doses three or four 
times a day. Every drop of breast-milk is so precious 
that no infant should be deprived of it, and wise is the 
physician who will insist on giving all the breast-milk 
when there is deficient lactation, and supplying the de- 
ficiency by giving a proper diluted milk- or cream- mixture, 
adapted for the age and weight of the infant. 

Do Drugs Taken hy a Nnrsing Woman Affect the Bal>y 
Dining the Nursing Period? — Physiological experiments 



:\IICROBES IX :\IILK OF XUESIXG WOMEX. 71 

liave frequently demonstrated the fact that a great many 
drugs can he given to an infant through its mothers milk; 
thus, opium and morphine and narcotics in general do 
affect the nursling when the drugs are taken hy the 
mother. Baginsky calls attention to this fact in his text- 
hook on "Diseases of Children'^: "Alcohol, when taken by 
the mother, is transmitted through the milk, hut not in 
very large quantities. The following is a list of drugs 
which have been found in milk: The jDurgative principles 
of rhubarb, senna, and castor-oil; the metals antimony, 
arsenic, iodine, bismuth, lead, iron, mercury; the volatile 
oils, like copaiba, garlic, and turpentine; also salicylic 
acid, and the iodides and bromides." Do not give cocaine, 
chloral, atropine, or hyoscyamus. Care to be used with 
the following: Digitalis, antii^yrin, and ergot. An un- 
pleasant flavor can be imparted to the breast-milk by the 
mother or wet-nurse eating onions, turnips, cauliflower, 
or cabbao'e. 



Microbes ix the Milk of N'uesixg Wo:\iex. 

EingeP^ examined the milk of 25 women, 1.2 of 
whom were healthy. ATith minute precaution to insure 
accuracy, he found the milk sterile in only 3 cases; he 
obtained the white staphylococcus in 17, the yellow in 2, 
the two together in 1 case, and in 2 instances he found 
the white staphylococcus together with the streptococcus. 
As the microbes could not be due to genital infection, 
the idea was sugo-ested that thev mio-ht come from the 



" Miinoli. Tiled. Woclienschrift, No. 27 : British Gynaecological 
Journal, xxxvi; Brooklyn Medical Journal. August. 1894. 



:/ 



72 INFANT-FEEDING. 

child's mouth, the white staphylococcus having been, in 
fact, found on the child's tongue. But having examined 
the milk of a woman who had not been suckling, but 
whose nipples had been disinfected, Eingel still found the 
staphylococcus. 

Sterility of Human Milk. 

Honigmann finds that human milk obtained with all 
antiseptic precautions from 73 breasts of 64 nursing 
women was only sterile, when duly cultivated, in 4 cases. 
In the remainder staphylococcus albus was present, and 
in 44 cases the staphylococcus aureus; while in 3 in- 
stances other bacteria — a bacillus and a sarcina — were 
found. The number of germs varied from 1 to upward 
of 9000 in a cubic millimetre. These observations are of 
interest in reference to the occurrence of thrush in chil- 
dren, to the origin of which they may furnish a clew, and 
also to the liability that children, while suckling, present 
to suppuration after wounds accidentally or intentionally 
inflicted. {Lancet.) 

Fat-globules. 

Woman's milk has larger fat-globules than cows' 
milk. Their number, according to Bouchut, is 1 to 2 
millions in 1 cubic centimetre. It has less inclination to 
turn acid; therefore it does not coagulate distinctly. 

Additional Foods During the Kursing Period. 

Flour-Ball Feeding. — When an infant nursing at 
the breast is six months old certain additions to 
the food can safely T)e made; thus, for example, the 



ADDITIONAL FOODS DURING NUESING PERIOD. 73 

white of a raw egg can be given every second day, 
and on the alternate day several teaspoonfuls of a meat- 
sonp (beef or chicken) in which barley, farina, or 
sago has been boiled and strained. This method of feed- 
ing can be kept np nntil the child is seven or even eight 
months old, and then a small piece of zwieback can be al- 
lowed every day. As this is hard, children like to nibble 
on it, for it seems to soothe their gums. If the bowels are 
in a good condition, then a few teaspoonfuls of a very 
light wheat-Hour ball can be given every few days. Flour 
ball can best be made by following the directions given by 
Dr. Edwin Eosenthal (paper read before the Pennsylvania 
State Society, May 18, 1898, entitled "Some Points on 
Infant-feeding''); he says: "1 use the following formula, 
and I can claim as much good results therefrom as from 
any form of modified home-made food. It is known as the 
flour-ball food, commercially imperial granum. It is made 
as follows: Plain wheat-flour is boiled in a bag for five 
hours, then dried, broken open, the rind rejected, and 
then grated into a powder. I take of pure milk, mixed 
and scalded, 1 pint; of sterile water, 1 pint; of the boiled 
flour, a heaping tablespoonful, a bit of cinnamon-bark 
(sometimes to give some flavor with certain children), and 
a pinch of common table-salt. The milk is placed on the 
fire and heated; the flour is rubbed to a fine paste with 
the water, and then added to the milk. The cinnamon is 
added, and then it is brought to the boiling-point, taken 
from the fire, the salt added (not suflicient to taste), and 
the whole is then placed on the ice. It is then heated 
again when used. Two ounces every two hours is given 
to a child one month old. It is increased ^/o ounce every 
month, while the water is reduced 1 ounce every month. 
The milk is added to keep the quantity up to the 2 pints. 



74 INFANT-FP]EDING. 

I have with this method seen some very surprising resj^ilts, 
and feel no hesitancy in recommending it/' 

The Addition of Hydrochloric Acid to Food. — The 
indiscriminate use of dilnte hydrochloric acid is a prac- 
tice that is to be condemned. We know that hydrochloric 
acid passes through the body unchanged^ and in being 
excluded by the kidneys frequently irritates the same. A 
point to note is that HCl is formed in the stomach from 
the chlorides in the circulation of the blood. It appears, 
therefore^ qnite plausible to add salt to the infant's food 
(ordinary table-salt: NaCl), which is likely to be trans- 
formed into HCl in the infant's stomach. 

The Feeding of Sick Children. — The method of feed- 
ing here is entirely different from feeding in health. No 
definite rules can be laid down as to the quantity or the 
quality, or the interval required for feeding; for example, 
if an infant suffering with dyspepsia will vomit, and have 
large, cheesy curds in the stools, and have anorexia, such 
an infant requires food that is far more diluted with water 
than heretofore. If, let us say, an infant, two months old, 
suffer with dyspeptic disturbance, and receives 2 parts of 
milk and 3 parts of water, such an infant should be given 
1 part of milk with 3 parts of water, to see if the dys- 
peptic condition cannot be modified. If no improvement 
is noted after several days of such feeding then it is wise 
to substitute barley-water instead of plain water, and 
thus see if the digestibility of the casein cannot be im- 
proved. If, however, no improvement is noted, then a 
good plan is to resort to predigested foods. It is in this 
class of cases that peptonized foods are so advantageous; 
but, if milk is badly borne, then it should be diluted with 
dextrinized gruels. 



I 



diet of a nursi^^g mother. 75 

The Diet of a E'uesing Mother. 

Immediately after the birth of the chikl the ex- 
hausted condition of a woman following labor will cer- 
tainly call for rest; hence sleep is imperative, after which 
some form of stimulation is required. This can best be 
accomplished by giving at intervals of several hours good 
wholesome food, as broth of chicken, or beef-broth, weak 
tea, or strained gruel. It is unnecessary to state that each 
woman's case and her former habits must be taken into 
consideration; and thus, if the labor has been normal, 
the nourishment will certainly stimulate the flow of milk. 
Great care, however, must be given to the usual irritable 
stomachs in this condition, and, if warm liquids are not 
well borne, then cold drinks, like buttermilk, koumiss, mat- 
zoon, or iced tea, should be employed. In some instances 
ice-cream will aid nutrition and allay gastric irritability. 
If the pelvic condition is normal, then it is wise not to give 
solid food for the first three days, but, rather, stimulate 
the milk-glands by giving meat-broths, farinaceous gruels, 
and by all means milk. Zwieback soaked in milk or in tea 
is highly nutritious and easily digestible. Other nutri- 
tious foods are calf's-foot jelly and chicken-jelly. 

After the third day — if the pelvic organs are normal 
— it is wise to consider the action of the bowels. If the 
bowels have not moved by this time, then buttermilk 
added to the diet or some stewed prunes or baked apples 
or stewed peaches, or grapes, will aid in establishing a 
movement of the bowels. 

If the milk is scanty and the bowels have not acted, 
then the best remedy is a large tablespoonful of castor-oil, 
modified to suit the taste by the addition of either orange- 
juice or lemon-juice, or by adding several drops of the 



76 



INFANT-FEEDING. 



ordinary spirit of peppermint. After the bowels have 
been eyaciiated and the general condition warrants it, 
then a diet consisting of the following is indicated: — 



Bkeakfast, 7 to 8 a.m. 



Hominy and Milk. 
Farina and Milk. 
Eice and Milk. 
Oatmeal and Milk. 
Germea and Milk. 
Cream of Wheat and Milk. 
Some Stewed Prmies, Figs, 

or Peaches. 
Stewed Apples. 
Oranges. 



Grapes. 

Soft-Boiled Eggs. 
Poached Eggs. 
Eggs on Toast. 
Coffee and Milk. 
Tea and Milk. 
Cocoa and Milk. 
Toast and Butter. 
Stale Bread (2 days old), 
with Butter. 



I do not advise meat nor fish in the morning, unless the 
nursing mother has always been accustomed to this form 
of diet. 



Lunch, 12 to 1 p.m. 

Some soup, made from meat, either veal^ beef, mut- 
ton, lamb, or chicken, containing also some rice, barley, 
farina, sago, or hominy; it should not be highly seasoned, 
and should not be strained. 

Fish, boiled or fried, and all shell-fish, particularly 
oysters, are very nutritious during the milking period. 

If the appetite warrants it, then a piece of steak or 
chop, roast beef, chicken (white meat only), or raw chopped 
meat, with l)read and butter, is very nutritious. 

Some fruit. 



I 



DIET OF A IsTURSING MOTHER. 77 

EVEI^ING, 6 TO 7 P.M. 

A bowl of Oatmeal Gruel. Junket. 

Some Oysters (stewed). Cup of Tea. 

A drink of Milk. Eggs^ if desired. 

Farina Pudding. Meat, if in the liabit of eat- 

Eice Pudding. ing it in the evening. 

Cornstarch Pudding. 

For Thirst. — Cool, filtered water or the alkaline 
waters, like Seltzer and Apollinaris. 

If the milk is scanty, the flow can- be stimulated by 
drinking a cup of hot broth, made from beef, chicken or 
veal, lamb or mutton, several minutes before putting the 
child to the breast. 

Alcoholic Drinks. — If a woman is in the habit of 
drinking beer or wine, then it is unwise to discontinue the 
use of alcoholics in moderate quantities, while she is nurs- 
ing. I have seen a great many women whose flow of milk 
was scant, that immediately secreted an abundance of 
milk after partaking of a glass of beer or ale or porter 
wuth their meals for several days. Beer has a decided 
laxative effect, and this in itself is rather an advantage for 
those nursing mothers having a tendency to constipation. 
So, my rule, therefore, would be to insist on abstinence 
from wine and beer unless the patient has been in the 
habit of taking it formerly. 

THIXGS TO BE ATOIDED BY A XURSIXG VTOMAX. 

Onions. Large quantities of pota- 

Garlic. toes. 

Cabbage. Butter and Fat moder- 

Powerful Salts (Rochelle, ately. 

Glauber, Epsom). Candies and too much 

Ethereal Oils. Sweets. 



CHAPTEE XII. 

Wet-nukse. 

If the infant's own mother cannot nurse her child, 
then we can and should try to secure a wet-nurse. 

The wet-nurse must be carefully examined, as well 
as her child, for the presence of syphilis. I beg to refer 
to a short paper on this subject, published in the American 
Medico-Surgical Bulletin in January, 189-1. 

1. jSTever have a baby fed by the milk of its mother if 
the latter suffer with general deljility or tul)erculosis. 
Extremely nervous mothers shouhl not nurse their babies. 

Syphilitic babies (hereditary) can only be nursed by 
their own mothers, owing to the risk of infecting the wet- 
nurse. 

Very frequently the life of the child is dependent on 
its being nursed by its mother in syphilis. 

(a) The return of menstruation is no contra-indica- 
tion to the continuation of nursing. 

(b) The moment a woman is pregnant nursing should 
be stopped. 

(c) Children should not be nursed ^t night unless for 
some special reason. 

(d) Weaning should take place gradually, and only 
in the eighth to the tenth month. 

(e) It is understood that weaning should not be com- 
menced during the hot summer weather. 

The main factor in determining the time of weaning 
is "weighing." Children must be weaned when, although 
in perfect good health, they remain below normal weight. 

(/) Prolonged nursing will induce rachitis. 

(78) 



WET-NURSE. 79 

2. If^ for various reasons^ a child cannot be nursed by 
its own mother^ we then resort to the wet-nurse. 

(a) She must be carefully examined as to her phys- 
ical condition; tuberculosis, all chronic disorders and dis- 
eases would prevent proper nursing. Hereditary nervous 
troubles, epilepsy, or syphilis would exclude nursing. 

(b) It is a good point to try to procure a wet-nurse 
suckling a child about as old as the one we wish her to 
nurse, although it is quite common to find nurses who 
have older children than the one they wish to nurse and 
to find the latter doing well. 

(c) The proof of the usefulness of the wet-nurse is 
the condition of the baby after some time. If the child 
thrives, it will increase in weight. Hence scales must be 
frequently used. 

DIET (wet-nurse). 

The diet given for a nursing mother can also be used 
as a guide in choosing the diet for a wet-nurse. The 
greatest care, however, must be bestowed on the 

Marnier of Living.— li.?^ wet-nurse was a former serv- 
ant, or worked out-of-doors and is suddenly taken into 
this new mode of life and given charge of a baby, she must 
have proper exercise, or else such wet-nurse will very soon 
secrete milk which will be totally unfit for an infant, and, 
as a result, the child will probably have severe colic and 
irregular, cheesy stools; will vomit excessively; and will 
not gain in weight sufficiently. It is, therefore, important 
to try and adapt a wet-nurse to the same condition as ex- 
isted prior to her pregnancy; so that both her manner of 
living and, chiefly, her diet shall not be different. 

Proper Best. — To be equal to her task a nurse must 
be given plenty of sleep, if it is at all possible. 



80 INFANT-FEEDING. 

Adriance^ in the Archives of Pedialrics, says: — 

1. Excessive fats or proteicls may cause gastro-inies- 
tinal syinptonis in the nursing infant. 

,2. Excessive fats may be reduced by diminishing the 
nitrogenous elements in the mother's diet. 

3. Excessive proteids may be reduced by the proper 
amount of exercise. 

-i. Excessive proteids are especially apt to cause 
gastro-intestinal symptoms during the colostrum period. 

5. The proteids, being higher during the colostrum 
})eriod of premature confinement, present dangers to the 
untimely-born infant. 

6. Deterioration in human milk is marked by a re- 
duction in the proteids and total solids, or in the proteids 
alone. 

7. This deterioration takes place normally during the 
later months of lactation, and, unless proper additions are 
made to the infant's diet, is accompanied by a loss of 
weight, or a gain below the normal standard. 

8. When this deterioration occurs earlier, it may be 
the forerunner of the cessation of lactation, or well- 
directed treatment may improve the condition of the milk. 

Methods of Changing the Ingredients in 
Woman's Milk. 

Eotch gives a condensed table for these changes as 
follows : — 

To Increase the Total Quantify. — Increase the liquids 
in the mother's diet, especially milk (malt-extracts may 
be helpful), and encourage her to believe that she will be 
able to nurse her infant. 

To Decrease the Total Quantity. — Decrease the liquids 
in the mother's diet. 



^ 



WET-NURSING. 81 

To Increase the Total 8olids. — Shorten the nursing 
intervals^ decrease the exercise, decrease the proportion 
of liquids, and increase the proportion of solids in the 
mother's diet. 

To Decrease the Total Solids. — Prolong the nursing 
intervals, increase the exercise, and increase the propor- 
tion of liquids in the mother's diet. 

To Increase the Fat. — Increase the proportion of meat 
in the diet. 

To Decrease the Fat. — Decrease the proportion of 
meat in the diet. 

To Increase the Proteids. — Decrease the exercise. 

To Decrease the Proteids. — Increase the exercise up to 
the limit of fatigue for the individual. 

It is wise in all cases of disturbed lactation, whether 
in maternal or wet- nursing, to make efforts in accordance 
with these rules to produce a milk that is suitable for an 
infant who is not thriving, before changing to any other 
method of feeding. 

Wet-nursing. 

It is an established fact that the best possible food 
for an infant is breast-milk. Where the mother of an 
infant is prevented from nursing her child, the next thing 
to be considered is wet-nursing. That nursing a child is 
an advantage to the mother is a well-known fact, inas- 
much as it influences the contraction of the uterus and 
stimulates the circulation. Contrary to the belief that 
nursing a child is detrimental, and contra-indicated in 
women whose lungs are weak and who have a tendency 
to the development of tuberculosis, it does them no harm, 
and, on the contrary, seems to do them good. This state- 
ment is borne out by the experience of Dr. Heinrich 



82 INFANT-FEEDING. 

Muiik, of KarLsbcul, Austria, a specialist for diseases of 
women. 

Ill Austria tlie State has public iustitutious for 1}^- 
iiig-iii women. They are kept there and confined gratis, 
and remain about fourteen days. They are admitted into 
these hospitals in the last months of pregnancy. Vienna 
usually has about 300 women on hand. Prague constantly 
has 100 women in this condition, who are utilized for the 
purpose of instruction to physicians and midwives. 

In Prague there are about 3000 women confined an- 
nually, and these women are put into the foundling- 
asylum. There they remain until they procure a place as 
a wet-nurse or as long as their services are needed in the 
asylum. When wet-nurses are taken from the foundling- 
asylum, it is a frequent occurrence to have those remain- 
ing therein nurse at least two children, and frequently, 
three, at one time. In this manner they dispense gradu- 
ally with these wet-nurses without hurting the remaining 
children. Many children die, some of them intrapartum 
in operative confinements, and the women (mothers of 
such children) are then utilized for wet-nursing. It is a 
rule to keep the children in the asylum until they have 
attained a little over four kilogrammes (about 9 pounds), 
and are then put out for further feeding (artificial feed- 
ing), for which the city pays about 12 florins a month 
($5.00). The children remain usually until they are six 
years old, and are then given back to their own mothers. 
Many of these children die, others are adopted by those 
who have reared them, but the greater portion are taken 
back by their own mothers. In Vienna there are about 
10,000 confinements annually in the public institution. 
There are a great many cities in Austria — like Innsbruck- 
Olmutz, Brunn, Linz, and Klazenfurt — where there are 



WET-NUKSING. 83 

at least 200 confinements annnall3\ In Vienna a wet- 
nurse receives 30 florins per months for which she is 
sent (railroad expenses paid) to whomever requires her 
services. She is taken on trial for fourteen days to see 
if she is adapted for her place. A wet-nurse can he 
procured b}- sending a telegram and a money-order any 
day during the year. The customary wages are from 12 
florins upward per month. Each wet-nurse is carefully 
examined by the professor before she is sent away. A 
great many families do not care to take a wet-nurse from 
an asylum, as they are usually women in the lowest walks 
of life, and prefer, therefore, to take a woman who has 
been married. For this purpose there are wet-nurse 
agencies, duly licensed. These will *supply wet-nurses, and 
usually take orders in advance; thus a wet-nurse may be 
reserved. Such wet-nurses cost much more, and those, 
from one special region — Iglau in Mahren — receive from 
20 to 50 florins monthly. 

The empress took for her own use a wet-nurse from 
Iglau (a married woman), and the Princess of Bulgaria 
took a wet-nurse from Iglau for her last child. Xot only 
Iglau, but the whole region, is renowned for its excellent 
quality of wet-nurses. The Bohemian and Mahren nurses 
have very good mammae. They seem to love those chil- 
dren intrusted to them. 

AMiile it is a rule that a wet-nurse should be taken 
for a baby of the same age as that of her own, frequently 
wet-nursing of an infant at birth by a wet-nurse whose 
baby is three months old has not been followed by any 
bad results. 

In Xew York we are at a decided disadvantage re- 
garding wet-nurses. As no licensed agencies exist, a few 
people having so-called influences procure wet-nurses by 



84 INFANT-FEEDING. 

iTiendsliip, or sometliing similar, from suporiiitendoiits 
and house physicians where obstetrical work is done. 

Thns we find ourselves at the mercy of some people 
who traffic in wet-nnrses for a fee, usually five dollars, 
and who do not stop at anything to attain their own selfish 
ends. 

Time and again have I sent for a wet-nurse to an 
agent who, instead of giving me a healthy wet-nurse, tried 
to induce me to use women having colostrum-milk for 
an infant in which such milk would have proved disas- 
trous. 

In another instance, only recently, I procured a wet- 
nurse from an agent who sent me one 17 years old that 
had had a premature birth, "evidently an abortion," whose 
milk was typical thin water, with here and there a fat- 
globule, when examined under the microscope. 

At other times some of the finest specimens of wet- 
nurses have also been procured from the same agent. 

It is a pity that we have no municipal control for 
what the writer considers one of the most valuable forms 
of adjuncts to our maternal feeding, and in the same 
manner such control would regulate the supply to such 
unlimited number that modern arrogance on the part of 
the wet-nurse would probably disappear. 

The prices paid in New York are from twenty to 
thirty dollars per month and board, and this price pro- 
hibits many an infant from securing the benefits of 
Nature's food. Let us hope for municipal regulation. 

Weaning, and Feeding ^rom One Yeae to 
Fifteen Months. 

Weaning should take place gradually between the 
eighth and tenth months. In some instances it is ad- 



WEANING AND POST- WEANING FEEDING. 85 

visable to commence weaning a child much sooner. For 
example, when there is a deficiency in the sup^^ly of milk 
or owing to ill health of the infant's mother. This I have 
already mentioned in my section on ''Mixed Feeding." 

Weaning is imperative when the infant's mother is 
pregnant, although it is advisable to use great caution if 
it occur in midsummer. In case of this kind the better 
plan would be to have a specimen of the breast-milk ex- 
amined by a chemist, and, if the same be found deteri- 
orated in quality, then the judgment of the physician 
must prevail as to the advisability of continuing or dis- 
continuing the nursing. My rule has been not to wean 
during the sunnner months. 

The main points have already been mentioned in this 
chapter under "Wet-nurse." 

Weaning should not be attempted suddenly. Thus, 
it is better to commence weaning gradually, by withdraw- 
ing the breast in the morning and substituting a bottle 
for that meal. Following this meal we can again nurse 
the child at the breast for two feedings, and substitute a 
bottle for its third meal instead of the breast. In this 
manner we can feed the child with a bottle in the morning, 
to be followed in three or four hours by the breast, then 
at the next feeding again nurse the child, and this to be 
followed in three or four hours by the bottle: — 

8.00 A.M Bottle. 

11.30 A.M N'ursing. 

3.00 p.M Cursing. 

6.30 p.M Bottle. 

10.00 p.M Breast. 

In this manner we can see just how the food is as- 
similated, and also study the individual peculiarities of 



86 INFANT-FEEDING. 

iJio l)aby. Some children ar.e very hard to wean, and it 
will require great tact and patience to successfully cope 
with this condition. I recently saw a child in consultation 
which, on heing removed from the breast, absolutely re- 
fused to take the bottle, and when fed with a spoon the 
child would spit its food out. After three or four days 
of this unsuccessful weaning the physician attempted 
more heroic methods, and insisted on isolating the child 
from the wet-nurse for twelve consecutive hours. This 
infant refused to take food even after that time, and then 
it was that I was summoned. We decided to give pep- 
tonized milk alternating with peptonized yolk of egg by 
means of rectal feeding. Thus, 1 ounce of mi]k and 1 
ounce of starch-water were injected, followed by the pe])- 
tonized yolk of egg added to the starch-water four hours 
later. This method of feeding can be found described 
i]T detail in the chapter on "Eectal Feeding.'^ And also 
the method of rectal feeding in the chapter on "Feeding 
in Diphtheria Intubation Cases." Thus we aim to sustain 
life and avoid starvation. The rectal feeding was con- 
tinued for two days more, when the child suddenly took 
the bottle. 

In some cases forced feeding by gavage will be found 
useful. If the child holds its jaws firmly, the catheter can 
be introduced through the nasal passage, as described in 
the chapter on "Nasal Feeding." 

I was called to see a perfectly healthy child, about 9 
months old, wdiose mother told me that "he would not 
take the breast." She was greatly chagrined, but all 
efforts at nursing him proved futile. The infant had 
weauod himself. Such cases of "autoweaning" are very 
rare. 



WEAXIXG AXD POST-WEAXING FEEDING. 87 

AFTEE-WEAXIXG DIET. 

When weaning is snccessfully accomplished, then 
great care must he exercised, owing to the change in diet. 
It will he fonnd that the slightest error in overfeeding or 
too frequent feeding will he rewarded b}^ a severe attack 
of dyspepsia and the usual gastric disturbances, such as 
vomiting and fermentation in the stomach, causing diar- 
rhoea and possibly colic. It will therefore be very neces- 
sary to exercise good judgment in the choice of both 
quality and quantity of food during the first month or two 
after weaning or until the stomach adapts itself to this 
new way of feeding. The amylolytic function now being 
thoroughly developed, we can safely give cereals. 

TIME OP FEEDIXG. 

Excepting in rare instances after a child is weaned 
it should not be fed oftener than once in four hours. The 
best time for feeding would be about 6 a.m., 10 a.m., 2 
P.M., 6 P.M., and 10 p.m. if the child is awake. This would 
give eight hours rest, and healthy children can be trained 
to sleep that amount. 

The first bottle after sleeping should consist of 8 
ounces of pure cows" milk.^'^ This would be the 6-a.m. 
feeding. 

Four hours later, or at 10 a.m., the infant should re- 
ceive the white of a raw egg fed with a spoon from a wine- 
glass immediately before its bottle, which consists of: — 

Cows' milk 5 ounces. 

Barley-water 2 ounces. 

At 2 p.:\r. our next feedino- shall consist .of 8 ounces 



^^ The best milk obtainable in this city is undoubtedly milk 
received direct from the dairy the same dav of milkino-. in bottles. 



88 INFANT-FEEDING. 

of pure cows' milk. I usually permit the infant to nibble 
on one-half piece of the ordinary zwieback. 
The evening meal at 6 p.m.: — 

Cows' milk 6 ounces. 

Barley-water 2 ounces. 

The last feeding at 10 p.m.^ if the child is awake, or at 
midnight shall consist of 8 ounces of pure cows' milk. 

When milk is brought from the dairy there is a thick 
layer of cream on the top of the milk, which should be 
thoroughly mixed with the milk by shaking the bottle so 
that the infant receives a thoroughly-mixed milk contain- 
ing the same quantity of cream in each feeding. The milk 
should be mixed and the barley-water added to it. It is 
then poured into thoroughly-clean bottles, which are stop- 
pered with ordinary cotton stoppers. This can be found 
described in detail in the chapter on ^^Sterilization." This 
food is to be steamed for twenty minutes and then allowed 
jto cool by placing the bottles in a refrigerator, but not 
on the ice. When ready for use each bottle is to be 
warmed to a temperature of about 100° F. for the feeding. 
If constipation follows the use of this diet, then a good 
plan is to substitute 2 ounces of oatmeal-water instead of 
the barley-water above mentioned. When the stools are 
regular and the child appears to be quite pale, then great 
good can be accomplished by adding 2 ounces of almond- 
milk instead of the oatmeal- or barley- water. The prepa- 
ration of almond-milk can be found described in the 
"Dietary," to which I beg to refer my readers. If a se- 
vere form of constipation, with cheesy curds in the stools, 
exists, then the milk should not be steamed, but fed in the 
"raw state." It is self -understood that it should be 
Avarmed to the body-heat before feeding to the infant. 



WEANING AND POST-WEANING FEEDING. 89 

Instead of giving the white of egg every day I substitute 
either 1 or 2 ounces of a good beef-soup or chicken-soup 
or beef-tea and expressed steak-jnice, and feed this quan- 
tity immediately before the 10-a.m. bottle of milk. No 
distinct change of food will be necessary until the child is 
twelve or fifteen months old, when I am in the habit of 
giving either ^/^ sancer of oatmeal-gruel with some butter 
or some hominy and butter in addition to a morning 
bottle. In the evening when the child arrives at this age 
a half-dozen teaspoonfuls of junket can be fed before the 
evening bottle of milk. At this age, Avhen a child is over 
one year or about fifteen months old, instead of giving 
water for thirst I frequently give prune-water made by 
boiling good fleshy prunes in water for one-half hour and 
straining ofl^ the liquid. When oranges can be procured, 
one or more teaspoonfuls of orange-juice can be given with 
advantage. Apple-sauce can also be given. Thus, my 
plan consists in giving each one of these foods on different 
days. Just at this period the addition of several tea- 
spoons of Mellin's food has been found very beneficial. 
Owing to gastric derangements, it will be found necessary 
to frequently discontinue milk entirely. At such times 
the use of the milk-foods — such as Xestle's food and 
Meltings food — has proved very beneficial. When diluting 
milk with the cereals like barley-water, rice-water, sago- 
water, flour ball and water, it is always better to dextrinize 
the diluents. This dextrinization has a decided effect on 
the casein, inasmuch as it splits up the curd, rendering it 
finely flocculent as it is found in human milk, and it is 
especially indicated in the period of weaning after the 
stomach has been accustomed to breast-milk and is sud- 
denly forced to digest cows' milk containing a more rub- 
bery and heavier casein, or curd. 



CHAPTER XIJI. 

Management of Woman's I^ipples. 
the management of the nipples before the 

BABY IS BOllN. 

It is very important during the last few months of 
pregnancy to devote considerable time and attention to 
the condition of the nipples. If these be found long and 
round, well projecting, then it is advisable to try to harden 
them, because the irritation from the child will cause con- 




Fig. 13. — Nipple-shield for Relief of Tender Nipples. 

siderable trouble unless we seek to prevent this. For this 
purpose wash in winter with lukewarm water, to which 
some alcohol has been added (2 teaspoonfuls of alcohol to 
a cup of lukewarm water). In summer cold water will be 
found more agreeable, using the same quantity of alcohol. 
If the nipples are very small and flat, and do not protrude 
properly, then suction by means of a breast-pump, applied 
directly over the breast, will draw them out. In some in- 
(90) 



BEE AST-PUMP. 91 

stances an ordinary clay pipe^ wliicli has a smooth bowl^ 
the latter to be laid over the nipple^ and the stem to he 
sucked or drawn, is satisfactory. This is to be repeated 
every few days. A few minntes of drawing out will suf- 
fice until the nipples are sufficiently prominent. Biedert^*^ 
gives the following prescription for hardening the nipples: 

Tannic acid 1 teaspoonful. 

Red wine 8 ounces. 

If red wine is not hand}^^ then substitute brandy in its 
stead. This is to be applied after thorough washing with 
soap and water, and removing crusts, if they are present. 

TENDEE XIPPLES. 

If, while nursing, the nipples crack and blood oozes 
from them, or if, from irritation of the child's gums biting 
them, the nipple is sore, then it is a good plan to allow 
the child to nurse through a nipple-shield. (See Fig. 13.) 

Xipple-shields can be used during the nursing act, 
and immediately thereafter the following salve can be 
smeared on the nipples: — 

IJ Zinc oxide, 1 drachm. 
Taselin, 1 ounce. — M. 

Beeast-pump. 

The breast-pump (Figs. 11: and 15) is a valuable addi- 
tion to the nursery. It should be kept scrupulously clean 
by inimersing it in boiling water containing a pinch of 
table-salt. In drawing a specimen of breast-milk for a 
chemical examination the breast-pump is very useful. If 
an infant is ill and refuses the breast, — as, for example. 



'Kinderernaehrung,'" fourth edition, 1900, page 110. 



92 



INFANT-FEEDING. 



if it has rhinitis or cold in the head, nasal obstruc- 
tion, preventing it from breathing, while the nipple is in 




1 



Fig. 14.— Breast-pump. 

its month, — such infants will take the breast and immedi- 
ately let go of it again. If the breast-pump is properly 




Fig. 15. — Breast-pump. 



applied, and the required quantity of milk drawn off, the 
infant can frequently be fed with a spoon slowly. 

In a serious condition, — as, for example, in a severe 



BREAST-PUMP. 93 

case of pneumonia with loss of appetite, — the life of the 
child may depend on forced feeding. This will be de- 
scribed in the section on "Gavage.'' It is very important 
to have the cup or any other receptacle into which we 
draw the breast-milk properly sterilized; otherwise the 
breast-milk will be infected in the same manner as has 
been described in detail in the sections on "Cows' Milk'' 
and "Bottle-feeding." 



CHAPTEK XIV. 

Infant's Weight. 

AYhen a child develops normally, at either breast- 
or bottle- feeding, then it increases from 6 to 8 ounces 
each week for the first two or three months. This gain is 
slightly lessened to^^-ard the end of the fifth or sixth 
month; bnt if a child thrives, then its gain, be it ever so 
small, mnst be steady from week to week. We have dis- 
tinct data on which to base our calculations, and any vari- 
ation from the normal should be can^fully investigated. 
If a child is breast-fed, and suddenly ceases to gain in 
weight, then a chemical examination of the breast-milk 
is imperative to know just what ingredient is wanting. 
If the child is bottle-fed, and the weight does not increase, 
then the formula is improper and frequently the addition 
of a larger quantity, or sometimes the changing of the 
quality, — as, for example, several ounces of cream instead 
of several ounces of milk, — will give the baby the requisite 
amount of food. 

Table showing the Gain in a Healthy Infant 
Fed at the Beeast. 



I 



Normal weight 


at birth, 


Gain at the end of the first 


7 lb. 




week, None. 


Weight when 3 


weeks old. 


Gain at end of 2 weeks, 


7 lb. 6 oz. 




8 oz. 


Weight when 3 


weeks old. 


Gain at end of 3 weeks. 


7 lb. 14 oz. 




8 oz. 


Weight when 4 


weeks old. 


Gain at end of 4 weeks. 


8 lb. 6 oz. 




6 oz. 


(94) 







infant's weight. 95 

The yital factor is certainly the general condition of 
the infant, whether it is bright and playful, sleeps 
quietly, and the condition of its stools. When the latter 
are normal as to color and frequency, then we may be sure 
that the baby is thriving. 

During the second month the infant should gain 
about 8 ounces per week; roughly speaking, an ounce per 
day is a good average. 

During the third month a child should gain an ounce 
per day, or about 2 pounds per month. 

x\fter the third month, an infant usually gains about 
3 to 4 ounces per Aveek; so that if a child has doubled its 
weight at the end of the fifth month, such a child should 
be considered normal, if the other conditions warrant such 
an opinion. An infant should weigh three times its 
weight at birth by the end of its f?rst year. 

Taking seven pounds as the average weight for an in- 
fant at birth, it should weigh 14 pounds at the end of five 
months and 21 pounds at the end of its first year. 

Weighing to determine the Quantity of MiTh an Infant 
has talcen Immediately After Nursing. — AVhen scanty milk- 
supply is suspected in either the nursing mother or in a 
wet-nurse, then we can, in some instances, resort to weigh- 
ing immediately after the baby has nursed. It is self- 
understood that the child must be weighed both immedi- 
ately before nursing and then immediately after nursing. 
The difference in weight is the amount of milk swallowed. 

AMiile this may serve in some cases, the author has 
not found it very practical, and cannot recommend it, 
excepting in rare instances. 

It is well known that an infant whose stomach is filled 
after nursing requires rest, and, the less it is handled, the 
less is the chance for expelling its food. Thus, my advice 



96 



INFANT-FEEDING. 



is not to liaiidlo or fumble Avitli a child after nursing, but 
rather aid Nature in resting an infant than try to provoke 
vomiting by unnecessary handling. 




I 



Fig. 16. 



Difference in Weight Before and Immediately After 
Nursing. — An infant should weigh, if under 3 months old, 
3 ounces more after nursing, and in older children,. 5 to 
G months, it should weigh at least 6 ounces more after 
suckling. 



INFANT S AYEIGHT. 



97 



Weight-chaet foe an Infant. 





Date 


Weight 






Kind of 


1 


\Vkek 


OF 


Weight 


Body- 
weight 


Food ; Quan- 


1 


AFTER 
HrilTH. 


OF 

Weigh- 


CHir.D 

WITH 


of 
Clothes 


tity AND 
Frequency 


Stools 




ing. 


Clothes 






OF Feeding. 




On tbe 














birthday. 














After 














1 ^veek . . 














2 weeks . 














3 ^yeeks . 














4 weeks . 














After 












5 weeks . 




« 








6 weeks . 




1 








7 weeks . 




j 








8 weeks . 




! 








After 


- — 










9 weeks . 














10 weeks . 








* 






11 weeks . 














12 weeks . 














After 














13 weeks . 














14 weeks . 














15 weeks . 














16 weeks . 




.. 










After 














17 weeks . 














18 weeks . 














19 weeks . 










► 




20 weeks . 














After 










21 weeks . 














22 weeks . 














23 weeks . 














24 weeks . 















After 












7 months. 














8 months. 














9 months. 














10 months. 














11 months. 














12 months. 















98 

Appearance. 
Specific Gravity 

Reaction. 
On Boiling. 
Coagulates. 



Coagulates on addi- 
tion of Lab-fer- 
ment. 

Fat. 



Varieties of Fat. 



Behavior of Various 
Acids. 



Milk-plasma Casein. 



Composition of Albu- 
minoids. 



Solids 



Quantitative Analy- 
sis, according to 
Soxhlet. 



Bacteria. 



infant-feeding. 
Properties of Hu.\[an Milk. 

Bluish, semitransparent, no odor, sweetisli. 

1.26 to 1.36. 

^ Amphoteric, relation of alkalinity and acid- 
( ity as 3 to 1. 

^ Does not coagulate, and forms a very thin, 
( hardly-perceptible skin. 

( At ordinary temperature after several 
( hours. 

Coagulates imperfectly in small isolated 
flakes, which do not precipitate as a uni- 
form coagulum. 

Yellowish white, resembling cow-butter. 
Specific gravitv at 15° C, 0.966. Melts 
at 34° C. 

( Butyrin, palmitin, stearin, olein, myristin. 
I caproin. 

< Few volatile acids. More than half of the 
I non-volatile consist of oleic acid. 

( Difficult to precipitate with acids and salts. 

I The precipitate redissolves in excess of 

j acids. During pepsin digestion there is 

[ no pseudonuclein produced. ^ ■ 

f Lactalbumin and lactoglobin; relation of 

I casein to albumin. 0.5 to 1.2 or 1 to 2.4: 

] of the 1.3 per cent, albumin, there are 64 

I parts of casein, and 37 parts of globulin 

i, and albumin. 

5 Less solids than in cows' milk, especialh- 
) CaO— P,0.,. 



Water, 87.41; albuminoids, 2.29; fat, 3.78: 
milk-sugar, 6.21; solids, 0.31. 

Usually sterile, rarely staphylococcus albus 
and aureus. 



PEOPERTIES OF HILK. 



99 



Peoperties oe Cows" Milk. 



Appearance. 
Specific Grayity. 

Eeaction. 

On Boiling. 

Coagulates. 

Coagulates on addi- 
tion of Lab-fer- 
ment. 

Fat. 

Varieties of Fat. 



Behavior of ^ ariou- 
Acids. 



Milk-plasma Casein. 



Composition of Albu- 
minoids. 



Solids. 

Quantitative Analy- 
sis, according to 
Soxhlet. 

Bacteria! 



Opaque white or whitish yellow, in thin 
layers bluish white, slight odor, faintly 
sweet. 

1.28 to 1.36. 



f Amphoteric: 
' "nd acidit 



relation between alkalinity 
ana aciaity, 2 to 1 : Soxhlet maintains 
that cows' milk contains three times the 
aciditv of human milk. 



Does not coagulate and forms a skin con- 
taining casein and lime-salts. 



J Coagulates very 
i formation. 



;oon. owing- to lactic-acid 



r Coagulates to a solid mass at body-tem- 
< perature, from which a yellowish fluid 
[_ can be expressed. 



j Yellowish-white mass. 
I 0.949 to 0.996. 



Sp. gr. at 15° C, 



Falmitin. olein. stearin, myristin. eaprilin. 
caprin. caproin. butyrin. laurin. lecithin, 
cholesterin, and yellow coloring matter. 

Volatile fatty acids, about TO per cent.: 
not volatile. 0.3 to 0.4 per cent, of oleic: 
the remainder consists of palmitic and 
stearic chiefly. 

Easy to precipitate with acids and salts: 
excess of acid does not dissolve; belongs 
to the nucleo-albumin group. 

Less lactalbumin and globin : the largest 
portion of the albuminoids is casein. 
Relation of casein to albumin. 0.3 to 3.0. 
or 1 to 10. 

.Cows* milk contains more solids than hu- 
man milk. 

Water, 87.17; albuminoids. 3.55 : fat. 3.69: 
milk-sugar, 4.88; solids, 0.71. 

Contains all milk bacteria, frequently also 
pathogenic bacteria, as typhoid, diph- 
theria, and tubercle bacilli, etc. 



LofC. 



CHAPTER XV. 

Raw Cows' Milk. 

The ideal cows' milk is clean, raw milk. By this is 
meant milk free from all possible contamination. Such 
milk should be obtained from a stable having all modern 
h^^gienic surroundings. If greater attention were bestowed 
on the condition of the cow, the cow's udder, the stable, 
the bucket, the hands of the milker, then less sterilization 
and pasteurization would be necessary. For let it l)e 
distinctly understood that certain 'chemical changes are 
brought about in milk, when it is steamed, be it in the 
]>rocess of sterilization or pasteurization. Keither pasteur- 
ization nor sterilization adds to the digestibility of milk. 
In fact, clinical experience has demonstrated the fact that 
raw milk, known in some places as certified milk, in the 
milk-laboratories in ^ew York City as guaranteed milk, 
is more easily assimilated, as proved by the condition of 
the stools as well as the gastric digestion. 

ISTature has given us a good example of how milk 
should be fed to an infant. Breast-milk is certaijily raw- 
milk, and is served to the infaut at a temperature of the 
body. Xot only does boiling or steaming milk produce 
chemical changes in the albuminoids, but it renders the 
process of digestion much more dithcult, and thus it is 
that most infants taking boiled milk suffer with constipa- 
tion. This is not so, however, in the case of infants fed 
on raw milk. 

When sterilized and pasteurized milk will be found to 
disagree with children, raw milk may sometimes be easily 
assimilated. Thus it will be found that, while boiled milk 

(100) 



RAW COWS^ MILK. 101 

or sterilized or pasteurized milk, given either whole or 
with its proper dilution to suit the various ages, will pro- 
voke constipation, by substituting raw milk instead of the 
heated milk the same will be more easily assimilated. The 
author has frequently noted decided antiscorbutic proper- 
ties in fresh raw milk. In children with decided rickets, 
and even scurvy, the withdrawal of sterilized or other 
milk, and the substitution of fresh raw milk will work 
surprising changes. 

Biedert, in his fourth edition of 1900, page 184, states 
that he has followed Escherich and Epstein, who recom- 
mend giving full milk to children at birth. In France 
Budin and H. de Eothschild, and more recently E. Schles- 
inger, in Germany, have given undiluted milk to both sick 
and well children as a substitute for breast-milk. Biedert 
claims to have seen good results in some instances, but 
cannot recommend wdiole milk, as a rule, for feeding chil- 
dren. Marfan, another advocate of pure-milk feeding, be- 
lieves that milk should be diluted until the fourth or fifth 
month, but later he advises pure-milk feeding. Schles- 
inger, of Breslau, while giving pure milk, gives a longer 
interval between the meals. That the greatest possible 
success is not achieved by this method of feeding in 
France can be judged by the statement of Marfan while 
discussing the subject of athrepsia. He says: '^Wa jamais 
vu Vathrepsie confirmee se terminer favoraUem&nt.'^ Thus 
is seems that even we have much better results than the 
French, for there are certainly a great many children who 
can and will digest a diluted milk, and thin milk- and 
cream- mixtures, as shown by their stool, the sleep, and 
increase in weight. These same children with enfeebled 
digestive functions will invariably show gastric disturb- 
ances, such as vomiting, colic, constipation or diarrhoea. 



102 INFANT-FEEDING. 

restlessness^ sleeplessness^ and cry continually; besides 
not increasing in weight. This method of feeding has 
been tried over and over again, and thus we will be com- 
pelled to discontinue the heavier food, consisting of pure 
milk, and substituting a light food, consisting of diluted 
milk. 

Fresh Eaw Milk. 

Just as the medical profession, and to some extent 
the laity, have become thoroughly impressed with the idea 
that milk should be boiled before being used, to insure 
the destruction of the microbes which it contains. Dr. 
Freudenreich comes forward with a series of experiments, 
by which he claims to prove that fresh raw milk possesses 
remarkable germicidal properties. According to his ex- 
periments, the bacillus of cholera, when put into fresh 
cows^ milk, dies in an hour, the bacillus of typhoid fever 
succumbs at the end of twenty-four hours, while other 
germs die at the end of var3dng periods. 

Milk which has been exposed to a temperature of 131° 
F. loses its germicidal properties. Milk which is four or 
five days old is also devoid of microbe-killing power. -^ 

Eaw-Milk Assimilation. 

Yasilieff,^^ in an inaugural thesis of 1889, in St. 
Petersburg, details experiments made on six healthy in- 
dividuals, varying from 18 to 23 years of age, restricting 
them for three days to a diet of fresh milk, and then for 
the three days following to boiled milk. The author 



-^Bacteriological World, December, 1891; Journal of the 
American Medical Association, February 27, 1892. 

--Journal de Medecine, May 4, 1890; Therapeutic Gazette, 
June 16, 1890. 



SCURVY. 103 

claims that liis experiments have proved that the assimila- 
tion of the nitrogenous principles of the toiled milk is con- 
siderably less than of fresh milk, although tlie difference is 
less marked than in the case of the fats. Nevertheless the 
faeces contain considerably more fatty acids after the ad- 
ministration of boiled milk than after the use of fresh milk. 
He therefore concludes that the nutritive value of boiled 
milk is much inferior to that of fresh milk. He explains 
these differences by the hypothesis, first advanced by 
Schmidt, that, by boiling, a part of the casein in cows' 
milk is transformed into hemialbnminose. 

« 

Scurvy. 

A paper on "The Uses and Prospects of Pathology," 
delivered at the opening of the Section in Pathology at 
the recent annual meeting of the British Medical Associa- 
tion, by Dr. W. Howship Dickinson, senior physician and 
lecturer on medicine at St. George's Hospital, states that 
a disease which presents itself as of chemical origin, if one 
due almost certainly to a specific deficiency in the con- 
stitueiits of the food may be so regarded, is scurvy, of 
which the chemical secret has apparently been so readily 
exposed that we ought to be almost within grasp of the 
chemical antidote. The conditions which give rise to sea- 
scurvy are generally known. It is not probably as widely 
recognized that scorlutic affections are so common on shore, 
among infants brought up by hand, that this form of land- 
scurvy is scarcely less important. It is to be attributed to 
the exclusion of fresh milk by various artificial prepara- 
tions of it. N'ot that these preparations are, in themselves, 
injurious, but they are insufficient. 

Milk in its fresh state, and of good quality, whether 
from biped or quadruped, is antiscorbutic; preparations 



104 INFANT-FEEDING. 

or sophistications of it are not so^ or not so to a sufficient 
extent. Scorbutic hgematuria and scurvy-rickets are but 
too frequent consequences of this substitution. We know 
the broad result, which is enough for practice, but we do 
not know the isolated want. What does fresh milk con- 
tain which is so essential and so difficult to preserve ? We 
no more know this than what there is in lemon-juice to bo 
antiscorbutic, while neither citric acid nor potash are so. 
The problem is attractive, like a puzzle; some day it will 
be solved, and then we shall w^onder w^hy it was not solved 
before. 

» 
Eaw Meat: its Beneficial Effect Experiment- 
ally Proved. 

Eichet and Hericourt announced, at the meeting of 
the Paris Societe de Biologic, June 2d, that they inocu- 
lated a number of dogs with tuberculosis more than six 
months ago. One-third were fed with ordinary food, and 
all died in three or four weeks; another set with cooked 
meat, with about the same results, while the third group 
was fed exclusively with the raw meat, and all have sur- 
vived to date and are in good health. 

Eaw Muscle-juice Possesses Antitoxic Properties. 

A. Sicard^^ says the effect of ^^zomotherapy" — as 
Eichet calls his experiments with 328 dogs inoculated with 
tuberculosis and then fed on raw meat — indicates that the 
raw muscle-juice has a specific antitoxic power in regard 
to the tubercle bacillus. The dogs survived, on an aver- 
age, 300 days, and some for two and a half years, while 
the control animals all readily succumbed. Sicard dis- 



Presse Medicale (Paris), June 13th. 



EAW MUSCLE- JUICE. 



105 



cusses the varioiis theories advanced to explain t];iese 
facts, and suggests that it would be interesting to cleter- 




Fio-. 17. 



mine whether other food-elements (codliver-oil, for in- 
stance), administered to dogs and guinea-pigs in sufficient 




Fig. 18. 

amounts, would have an in]ii])itiug action on the evolution 
of experimental hacillosis: also whether forced ino-estion 



lOG INFANT-EEEDING. 

of raw or dried meat would transform the cellular or 
humoral medium in animals and render them refractory to 
infection. 

Infant-feeding.--^ 

It is impossible to go over the broad domain of arti- 
ficial feeding in the time usually alloted to a discussion 
and do justice to all the interesting papers presented. 
Let me^ therefore, give you in brief Avhat would be my 
personal views based on clinical experience. 

My first proposition in hand-feeding is: Secure the 
best possible cows^ milk from a reliable dairy. The hy- 
gienic condition of the cows' stable to be in accord with 
modern sanitary laws; so that the principle of steriliza- 
tion is applied to everything from the stable to the cow, 
to the milker's hands, and to all utensils used in milking 
and transportation, exactly as given by Professor Bagin- 
sky in his paper, which I had the honor to read at the 
last meeting of the Section on Diseases of Children at At- 
lantic City, June, 1900. Summing up, then, asepsis — 
which is really nothing but absolute cleanliness — should 
be rigidly enforced. 

Second Proposition. — Imitate Nature in feeding, using 
raw milk. In this way we copy from Nature just what she 
has ordained for woman to feed, for it must be admitted 
that breast-milk (woman's) is raw milk. It is neither 
boiled, sterilized, nor pasteurized. When the precautions 
mentioned in my first proposition are carried out, there is 
no risk of infection. 

Do we ever stop to think how many millions of mi- 



-* Discussion on infant-feeding, Academy of Medicine, October 
18, 1900, by Louis Fischer, M.D. Archives of Pediatrics, January, 
1901. 



INFANT-EEEDING. 107 

crobes lie dormant in tlie gastro-intestinal canal ready to 
reinfect the sterilised milk? My plan is to give pure milk 
(properly diluted or pure) if the age warrants^ and merely 
warm it immediately before feeding it to the infant — 
temperature of 100° F. 

We know that a great many children fed on sterilized 
milk develop scurvy. The same holds of children fed 
on boiled milk. The reason is, Eundlett so ably says: 
"Changes take place not in the albumin, fat, nor sugar, 
but in the albuminate of iron, phosphorus, and possibly 
in the fluorin vital changes take place. These albumi- 
noids are certainly in the milk, derived, as it is, from tis- 
sues that contain them, and are present in a vitalized 
form, as proteids." 

On boiling, the change taking place is simply due to 
the coagulation of the globulin, or proteid molecule, which 
splits away from the inorganic molecule and thus renders 
it, as to the iron and fluorin, unabsorbable, and, as to 
the phosphatic molecule, un assimilable. This is the 
change that is so vital, and this only takes place when milk 
is boiled. 

It is evident that children require phosphatic and 
ferric proteids in a living form, which are only contained 
in raw milk. 

Cheaclle says that phosphate of lime is necessary to 
every tissue; no cell-grow^th can go on without earthy 
phosphates; even the lowest form of life — such as fungi 
and bacteria — cannot grow if deprived of them. These 
salts of lime and magnesia are especially called for in the 
development of the bony structures. 

Avoidance of Scurvy. — Since clinical experience has 
demonstrated that the prolonged use of sterilized and 
boiled milk will produce scurvy, and that improvement is 



108 INFANT-FEEDING. 

immediately noted when raw milk is given or raw muscle- 
juice (beef-juice) or raw white of egg, added to fresh fruit- 
juices, does it not seem more plausible to commence feed- 
ing at once with raw milk ratlier than after scurvy or 
rickets is developed? 

There is a certain deadness, or, to put it differently, 
absence of freshness, that is lacking in milk that has been 
boiled or sterilized, just as it is the absence of fresh meats 
and green vegetables which is known to cause scurvy in 
the adult. 

GENERAL RULES FOR FEEDING INFANTS. 

Each child is a law unto itself, and its individual 
wants must be studied. One child will gain on the same 
mixture on which another will lose weight. The proof of 
the proper assimilation of food in any and every child will 
be the following: — 

The infant must appear satisfied after taking its 
bottle. There should be no vomiting nor severe colicky 
pains. 

The bowels must move (unaided) at least once or 
twice in twenty-four hours. They should be yellowish 
white and medium soft. 

The infant should sleep from four to eight hours at 
one time during the night. 

The weight must be taken regularly once a week. If 
an infant thrives it should gain at least from 6 to 8 ounces 
every week. When child^s weight shows no increase, then 
study the reason, and by all means change the food; give 
more substantial food. 

LABORATORY-MILK. 

The sentiments expressed at the last meeting at the 
;\cademy of Medicine by A. Jacobi coincide with my 



INFANT-FEEDING. 109 

views. My experience has been that children fed on labora- 
tory-milk have been backward in their development after 
its nse for a long time. AYhen first nsed children suffered 
Avith severe constipation; later, a distinct atony of the 
stomach and bowels was seen, poor a]3petites requiring nnx 
vomica, delayed dentition, and finally rickets developed. 
Such children always looked pale, were anaemic, and their 
flesh was flabby. As these cases were among wealthy 
people with the best possible hygienic surroundings and 
careful nursing, the cause could only be looked for in the 
method of feeding. I have not had an opportunity to 
study this method of feeding in a tenement-house iiifaur 
with unsanitary surroundings. The percentage method 
of feeding has always appeared to me plausible in theory, 
but it cannot be applied in practice. Mothers' milk 
changes almost at each nursing, and we know by chemical 
analyses that this is true several times a day. It would, 
therefore, be necessary, if we intended to imitate Xature, to 
change the formula of an infant's food several times a day. 
It is a fact well known to chemists that once an emul- 
sion of milk is broken up by centrifuging or other mechan- 
ical process, as in separating the top-milk from the skim- 
milk, we cannot have again as homageneous an emulsion 
as prior to this l)reaking up of the same. And, more- 
over, that we add to the trouble when we, in addition, seek 
to improve the quality of the milk by subjecting it to the 
process of sterilization. 

SUBSTITUTE FOR MILK IN DISEASES OF STOMACH 
AND INTESTINES. 

When milk disagrees and the infant's stomach will 
not tolerate the same, and vomiting is provoked, or when 
gastro-intestinal trouble arises, then milk must be 



110 INFANT-FEEDING. 

stopped. At siicli times I have seen very good results 
follow the use of almond-milk (see "Dietary"). 

Dextrinization is successful in children having sub- 
normal gastric digestion. The author does not advise the 
dextrinization of food for healthy children, but only in 
feeble, ill-nourished, and weakened conditions. 



CHAPTEE XYI. 

Cows^ Milk. 

Ham^ieesten^^ gives Ivonig's analysis of milk in a 
thousand parts as follows: — 

Water 874.2 

Solids 125.8 

Fat 36.5 

Sugar 48.1 

Salt 7.1 

Proteid (casein, 28.8; albumin, 5.3) 34.1 

Prof. A. Baginsky-*' gives tlie following analysis of 
cows^ milk^ made at the Kaiser and Kaiserin Friedrich 
Hospital^ Berlin: — 

Water 87.60 

Solids 12.38 

In one hundred parts. 

The solids consist of: — 

Casein and albumin 3.65 

Butter 3.11 

Milk-sugar 4.54 

Inorganic salts 1.08 

Besides large amounts of potassium and potassium 
salts and small quantities of iron. 

COMPOSITION, VARIATION, AND PRODUCTION. 

Milk of all animals, roughly speaking, is composed of 
the same ingredients, but an analysis of milk is apt to be 

23 "Physiological Chemistry." 

-" "Diseases of Children/' 1899, page 32. 

(Ill) 



112 



IN FA N T-FE Ei) J N ( I . 



very iiiisleadiiio-, as ii does not sliow the physical condi- 
tion of tlie milk, which is the important thing to know 
from the physician's stand-point. 

The general ingredients of milk are fat, sugar, albu- 




Fig. 19. — Cows" Milk, showing Fat-globules. Magnified, 
330 Diameters. 



iiiin, casein, mucin, salts, and water. These ingredients 
vary greatly in quantity from day to day and from milk- 
ing to milking. An average analysis of woman's milk 
does not show what an infant is getting, by any means. 



cows' MILK. 113 

for the composition of the milk depends on the food and 
health of the mother and the frequency of nursing. 

It seems to be pretty well settled that the fat in 
woman's milk usually varies between 3 and 5 per cent., 
the sugar between 4 and 8 per cent., proteids (albumin 
and casein) between 1 and 2 per cent., and the ash be- 
tween 0.3 and 0.4 per cent., the water being about 88 
per cent. ~\Yide extremes are met with; so it is useless to 
think of woman's milk as of a certain composition. 

Cows' milk, which is the only milk worth consider- 
ing in connection with artificial infant-feeding, shows 
great A'ariation in composition, just as does woman's 
milk. There is no such thing as average cows' milk. 
It may be that the mixed milk of a particular herd of 
cows will run uniform in composition for a long time, 
but this is because the variations in the milk of individual 
cows offset each other. A difference of 25 per cent, in the 
amount of fat in night and morning milk has been noticed 
in the milk of some cows. This is why "one cow's milk" 
should not be used. Mixed milk of different herds of cows 
will vary between 3 and 5 per cent, fat, 4 and 5 per cent, 
sugar, 3 and 4 ^ /^ per cent, casein and albumin, while the 
ash runs about 0.7 per cent, and the water about 88 per 
cent., all depending on the breed of cows and their food. 
Some breeds give large quantities of milk poor in solids, 
while others give smaller quantities of milk rich in solids. 

As a general rule, the shorter the interval between 
milkings, the richer the milk is in solids. Dry food in- 
creases, and succulent decreases the quantity of solids in 
the milk. Slight febrile conditions increase the quantity 
of fat and albumin; depression reduces fat and albumin. 
Casein, sugar, and ash are the least variable ingredients. 

The composition of the fat of milk and the size of 



114 INFANT-FEEDING. 

the fat-globules vary with the period of lactation, the 
breed of cows, and the kind of food used. Linseedmeal is 
said to make a soft, oily fat, while cottonseedmeal and 
some other foods make a hard fat. Small, hard fat-glob- 
ules are noticeable when the animal becomes pregnant. 

The practical problem before the physician in bottle- 
feeding is to prepare a food that approximates mothers" 
milk in composition and physical properties. To get good 
results good cows' milk must be used, and the physician 
should know that this can be had anywhere if strict clean- 
liness is observed by the milkman. 

Aside from the difference in composition between 
cows' milk and woman's milk, cows' milk often contains 
lactic acid and other products of bacterial growth, which 
may cause digestive disturbance. The lactic acid is the 
result of the growth of the lactic bacteria that are always 
found in milk and which get in the milk from the dirt 
in the stable. 

Good milk can be had by keeping the cows clean and 
wiping them off with a damp cloth just before milking. 
The first three or four jets from each teat should be 
thrown away, as they are always infected, and then the 
milking should be continued into a clean pail. The milk 
should then be immediately cooled to below 45° F., at 
which temperature there is little or no growth of bacteria. 
Unless this is done the bacteria that always get into the 
milk no matter how much care is exercised, will grow 
rapidly, and, after they have had a start, all the care pos- 
sible will not repair the damage. Milk produced as de- 
scribed has been known to keep in good condition in sum- 
mer in a refrigerator for three weeks and it is not at all 
unusual to buy bottled milk in Xew York that is forty- 
eight hours old that will not redden litmus-paper. 



TUBERCULIN REACTION IN COWS. 115 

C'ows^ Food. — The natural food^ fresh grass^ is the 
best; next to this hay is the best. The greater the propor- 
tion of nitrogen in the food^ the greater is the yield of 
milk, the proportion of fat being especially high. Feeding 
cows with brewers' grain depreciates the quality by lower- 
ing the total solids of the milk. Such feeding is illegal in a 
great many States, particularly Wisconsin. Beets, carrots, 
and swedes increase the proportion of milk-sugar. 

Average Percentage of Fat. — The average percentage 
of fat found is 4 per cent. This does not vary, and the 
uniformity of milk, particularly in ^ew York City, is cer- 
tainly due to the extreme care and vigilance of the Board 
of Health of our city. It is not surprising that milk is so 
frequently adulterated when it is possible to add about 
20 per cent, of water or 30 per cent, of skimmed milk to 
milk of average quality without the resulting mixture 
falling below the present requirements. 

Tuberculin Reaction in Cows. 

Conclusions as to the tuberculin test, in the Bulletin- 
of the Massachusetts Agricultural College: — 

1. Tuberculin furnishes a very delicate and reliable 
test, and is the only means by which tuberculosis can be 
stamped out. 

2. A certain number of sound cows will show the 
tuberculin reaction. 

3. A certain number of tuberculous cows will not 
show the tuberculin reaction. 

The Cattle Coiumissiouers of Massachusetts had, at 
Brighton, on February 15, 1895, 40 cattle which they had 
subjected to the tuberculin test and condemned as tuber- 
culous. The figures of the tuberculin test were carefully 
reviewed at the office of the commission in Dorchester, 



IIG INFANT-FEEDING. 

and it was decided that 13 of the lot should be killed on 
that day. 

There were present Commissioner Herrick and Dr. 
Lyman^ secretary of the commission; Dr. Burr, inspector 
for the City of Boston; and Dr. Way, acting in behalf of 
the owners. 

At the last moment it was discovered that 3 cows had 
not been appraised and 10 only were killed. 

Two of the 10 were undoubtedly tuberculous. Four 
were pronounced to be so by Commissioner Herrick and 
Dr. Lyman, but declared not to be so by Dr. Way. Their 
organs were, therefore, sent to Professor Whitney, of 
Harvard College, for microscopical examination. In 1 of 
these 4 cows an abscess was found in which was a short 
nail which had apparently caused it. By the most care- 
ful examination the commissioners could find no signs of 
tuberculosis in the 4 remaining cows, and they were ac- 
cordingly dressed and sold for beef .^^ 

Causes of Tubeeculous Diseases in Childken. 

Dr. J. Walter Carr^^ has made investigations as to 
the starting-point of tuberculous disease in children; he 
made post-mortem examinations in 120 cases of children 
who died at the Victoria Hospital, Chelsea, Eng., of vari- 
ous forms of tuberculosis. He concluded that in two- 
thirds of the cases the disease began in the thorax and 
evidently was not due to tuberculous milk (that is, infec- 
tion from the food) and that milk is by no means a fre- 
quent channel of infection as compared with infection by 
the lungs. It is often asserted that tuberculous milk 



-' "Spy," Worcester, Mass. 
-« Lancet, May 12, 1894. 



SOUE MILK. 117 

causes the greater part of deaths in children; even sum- 
mer diarrhoea, cerebral meningitis, peritonitis, "consump- 
tion of the bowels," etc., are laid to the door of tubercu- 
lous cows. The fallacy is that consumption (tuberculosis) 
in children is a generalized condition; in the adult, a 
localized condition. The mesenteric glands are often af- 
fected in children, but careful examination shows that the 
starting-place was in the thorax. The point is, not what 
organs are affected at death, but in what organ the disease 
begins. Dr. Carr says that bacilli are omnipresent, and it 
is impossible to keep a child from contact with them. 
The great points in the prevention of tuberculosis in chil- 
dren are the maintaining of perfect health and avoiding 
respiratory and gastro-intestinal catarrh, and keeping the 
mucous membrane healthy. 

Yellowish Milk. 

Before and after calving milk is yellowish, due to the 
presence of small, yellow bodies. Such milk is called 
colostrum, and in the case of cows is unfit for human con- 
sumption. 

Pus-cells rather larger than the red blood-corpuscles, 
granulated, and with a core or irregular contour, are found, 
as are blood-corpuscles in the milk of sick cows. They are 
prevented, as Soxhlet has pointed out, from coalescing into 
an oily film by the condition of the albumin, which isolates 
the fat-corpuscles in its meshes. 

Sour Milk. 

When milk stands for some time, fermentative 
changes due to a micro-organism — usually iacilhis acicli 
lactic i — take place. This decomposes the milk-sugar, re- 
sulting in the production of lactic acid, which eventually 






118 INFANT-FEEDING. 

causes the milk to become sour. The change is very largely 
dependent upon the time the milk has been allowed to 
stand, and more particularly upon the temperature of the 
place. 

When the fermentative change has resulted in the 
production of about 0.4 per cent, of lactic acid, the milk 
can be distinctly recognized, by the taste, to be sour. 
When the acidity reaches 0.6 per cent, the milk curdles, 
and it spontaneously separates into a solid, known as curd, 
which consists of the fatty and proteid constituents of the 
milk, and a clear liquid known as whej, which consists 
essentially of a solution of milk-sugar and mineral salts. 
This same change is brought about artificially when we 
add rennet. 

Fkozen Milk. 

Partial freezing of milk produces a concentration of 
the solids in the part remaining liquid, while the part 
frozen is deficient in them. In winter, Avhen milk has 
undergone a partial freezing, great care should be taken 
to allow it to thaw and then to thoroughly mix the same 
before allowing it to be sold. 

Koumiss. 

This is a preparation of mares' or asses' milk in a 
partly-fermented condition largely used in Eussia. It is 
prepared as follows: The milk is allowed to cool, and is 
then deprived of a part of its cream; a little yeast is then 
added. This sets up a slow fermentation, the milk-sugar 
being converted into alcohol and lactic acid. During the 
fermentation the milk is subjected to frequent agitation, 
the object of which is to maintain the casein in suspen- 
sion, which has a tendency to separate during the fer- 



DETECTIOX AND ADDITION OF PEESERYATIYES. 119 

mentation. Konniiss (called Knmyss) is prepared in this 
conntry frcm cows' milk. The chief manufacturer is Dr. 
E. P. Brush, of Mt. A^ernon, i^. Y. Another preparation 
which I have used is known as zoolak and is made by Dr. 
Dadirrian. 

Detection and Addition of Preseryatites to Milk. 

Those most frequently employed are: Borax and 
boric acid, formaldehyde, salicylic acid, and potassium 
chromate. 

Formaldehyde-^ is the most effective, and, when the 
same becomes better known, it will supersede all other 
preservatiyes. The above chemicals are sold to farmers 
and dair3'men as ^'milk-preservatives.'^ The table on the 
following page will show the efficiency of the various milk- 
preservers, and is taken from T. H. Pearmain and C. G-- 
Moor, on ''Milk and Milk-products.^^ 

Formaldehyde is usually added to milk in the form 
of a -iO-per-cent. solution, commonly called formalin; 2 or 
3 drops added to a pint of milk will keep it fresh for three 
or four days, and the addition of 0.05* per cent, will pre- 
serve milk for months. In the trade a much more dilute 
solution is generally employed, namely: 1 part of formal- 
dehyde to 80 parts of water. Eideal states that a quarter 
of a pint of such a solution will keep seventeen or eighteen 
o-allons of milk fresh for at least three days, and will not 



-® The Xew York Medical Record, as recently as July 21, 1900, 
contains the folloAving: — 

"Many milk-dealers in Xew Jersey have been arrested on the 
complaint of the State dairy commissioner for adulterating milk, 
the special adulterant being formaldehyde, added as a preserva- 
tive."" 



120 



INFANT-FEEDING. 



After 11 Days. 

liACTic Acid, 
Per Cent. 


C 




IF 


a* J, 
02 


1^ 




IS 


(M 

o 




o 


After 8 Days. 

Lactic Acid, 
Per Cent. 


s 
" 


1^. 
1- 


Is 


4-3 


^ i Is 


li 


1^ 


=00 


After Standing 
7 Days. 


p 


1 


1 1 
: 1 

■^^ ' -^^ - r, 

S ? i ;i 

CO <« isg 


% 

is " 

02 


1 i i 
I i 1 


1 


5 . 

II 

r 


o 
U2 


4J 


02 


0? 




1 

1 


1 






i 

a 

fc 03 

H 

<5 


s 
5c 






4J 
0) 

02 


1 

02 


i 

3D 


1 
02 


+3 

I 

02 


02 




>5 




& 1 ^ ' ^ 

as • j 02 1 a: 

i 


02 


1 
02 


O! 


+5 

02 


Grains of 

Preservative 

Used PER Gallon 

OF Milk. 






5 
o 

lO - 

s 

o 


4^ 

i 
i 

o 


o 
o 


s 

CO S 

o 




4^' 

c 
o 


4J 

i 

CO S 

o 




r 










III 

g 


':3 

1 . 

o 

c3 


m 


o 

o 
02 


1 

li 
02 


1 

o 
c 

1 



DETEGTIOX A^B ADDITION OF PRESERVATIVES. 121 

impart any smell or taste to th§ same. On tasting milk 
containing formaldehyde a peculiar sensation is noticed 
at the back of the throaty and when strong hydrochloric 
acid is added to it (Werner Schmidt process) the casein 
turns yellow and is less soluble than that of pure milk. 
Hehner's test is the most reliable. When milk, formalin, 
and sulphuric acid are mixed together a blue coloration is 
formed. According to Eichmond and Bosely, it is best to 
dilute the milk with equal quantities of water and add 
sulphuric acid, about 90- to 91:-per-cent. strength. When 
formalin is absent, the milk gives a sUglit-rjreenlsli tinge 
at the junction of the two liquids, while a violet ring is 
formed when formaldehyde is present. This color remains 
permanent for several days. In the absence of formalin, a 
brownish-red color is developed after some hours, not at 
the junction of the two liquids, but lower down in the 
acid. This cannot be mistaken by anyone who has had 
any experience with the test for the formaldehyde reac- 
tion. It is stated that 1 part of formalin can ie easily de- 
tected 1)1/ means of this test in 200,000 parts of milk, but the 
blue coloration is not obtained with milk containing over 
0.5 per cent. 

Another very sensitive test for the detection of forma- 
lin in coirs' milk is the following: If to the distillate from 
a sample of milk 1 drop of a dilute aqueous solution of 
phenol is added and the mixture poured upon strong 
sulphuric acid contained in a test-tube, a bright-crimson 
color appears in the zone of contact. This color is still 
readily seen with 1 part of formaldehyde in 200,000 of 
water. If there is more than 1 part in 100,000 there is 
seen above the red ring a white, milky zone, while in 
stronger solutions a copious white or slightly-pink, curdy 
precipitate is obtained. This reaction has an advantage 



122 INFANT-FEEDING. 

over the one previously referred to^ as it is obtained with 
formaldehyde solutions of all strengths, while the blue 
color of milk is not obtained wdth milk containing much 
formaldehyde. 

Salicylic acid is not very much in vogue as a milk- 
preservative. It can easily be detected by Pellet's method: 
200 cubic centimetres of the milk are diluted with an 
equal measure of Avater, heated to 60° C. and treated 
with 1 cubic centimetre of acetic acid and an excess of 
mercuric nitrate free from mercurous salt. The salicylic 
acid is extracted from the filtered solution by agitation in 
ether and recognized by evaporating a little of the ethereal 
solution to dryness and testing the residue with ferric- 
chloride, which gives a violet color with salicylic acid. 

Pearmain and Moor, in describing the bacteriology of 
milk, say that it usually contains a large number of bac- 
teria derived from the external surroundings of the cow. 
Where these are unclean, the number may reach three or 
more millions 'per cubic cent'} metre. These can, "for experi- 
mental purposes," be completely separated by filtration 
through Pasteur tubes, the tubes being cleaned at short 
intervals. A thin, watery serum constitutes the filtrate, 
the whole of the fat being arrested with the organisms, so 
that milk cannot therefore be freed from organisms for 
practical purposes by any known system of filtration. 
Milk can be curdled by ferments even in the absence of an 
acid reaction. The most notable ferment is rennet, ob- 
tained from the stomach of a calf. Hueppo first pointed 
out that such ferments are conveyed by many different 
bacteria which precipitate the casein in the presence of a 
weakly-acid, amphoteric, or even neutral solution. The 
numerous tyrothrix bacilli isolated by Duclaux, the bacil- 
lus pyocyaneus, yellow sarcina, and particularly the organ- 



DETECTION AND ADDITION OF PRESERVATIVES. 123 

isms described by Fliigge/^ characterized by their capacity 
to peptonize niilk^ belong to this class. Cohn^^ produced 
the precipitation even by means of bacteria, of which the 
vegetative capacity had been completely abolished with 
chloroform, thns showing that the fermentative action 
was due to a substance independent of the metabolic 
products of the organism. These substances have been 
isolated by Cohn and others. They are destroyed in most 
cases at from 65° to 75° C. Some ferments, how^ever, as, 
for example, that flescribed by Gorini in association with 
the bacillus prodigiosus, resist as much as an hour's ex- 
posure to 70° or 80° C, and require at least half an hour's 
exposure to 100° C. (or 312° F.) for their destruction. 

It is practically inevitable that milk, as delivered 
from the cow, should contain a nimiber, and usually a very 
large number, of bacteria. The extent of their presence 
is, however, affected by many circumstances, of which 
some are also indications of unwholesomeness or danger. 
Many of the organisms which are capable of causing 
disease do so by producing toxic decomposition-prod- 
ucts from the milk. Their vegetative capacity increases 
greatly with rise of temperature, and it is therefore an 
essential condition of sanitary milk-production and espe- 
cially of the designation of a milk as suitable for children 
that it should be kept at a low temperature during the 
whole of the interval between beino- drawn and beino- con- 
sumed. 

Yellow milk is stated to be colored by the bacillus 
synxanthus of Schroter, the color being removed by acids 
and restored bv alkalies. 



^° Zeitschrift fiir Hygiene, xvii, page 272. 

^ Centralblatt fiir Bacteriologie, ix, page 653. 



124 INFANT-FEEDING. 

Salty milk is stated to occur only in connection with 
inflammation of the udder. It is to be detected not only 
by its taste and its high percentage of ash, but by its low 
percentage of milk-sugar. Its specific gravity is 1.027 to 
1.029. According to Klenze, 2.4 per cent, of small de- 
posits of calcium carbonate in the milk-glands may give 
rise to sandy milk. Curious results have been noted by 
Scheurlen/- in experimenting with bacteria in milk. He 
found that milk can be freed from bacteria by the opera- 
tion of a centrifugal machine. He also noted that, of the 
large majority of bacteria contained in milk, three-fourths 
went into the cream on being centrifugalized, and the rest 
stayed in the separated milk, and the same result was ob- 
tained by merely leaving the milk stand. These results 
held good not only for the ordinary milk bacteria, but also 
for anthrax, typhoid, and cholera. The tubercle bacillus 
only remained to a small extent in either the milk or the 
cream, and the large majority was ejected under the cen- 
trifugal influence. The biological commission on milk- 
supply held under the auspices of the British Medical 
Journal for 1895, reported the following: 1. That all 
milking be carried on in the open air, the animal and 
operators standing on a material which is capable of being 
thoroughly washed, such as a floor of concrete or cement. 
Such a floor could be easily laid down in any convenient 
place which can be found. The site chosen should be 
removed from inhabited parts as far as possible, and 
should be provided with a plentiful water-supply. Only 
in this way does it seem possible to avoid the initial con- 
tamination with the colon bacillus. 2. That greater care 
should be expended on the personal cleanliness of the 



^-Arbeiten a. d. k. Ges, Amt., vii, 1891. 



TIME AND STAGE OF MILKING. 125 

cows; tlie only too familiar picture of the animaFs hind- 
quarters, flanks, and side being thickly plastered with mud 
and faeces is one that should occur no longer. It would 
not be difficult to carry out this change. Indeed, in the 
better managed of our large dairy companies^ farms such 
a condition no longer prevails, but in the smaller farms 
it is but too frequently met with. 3. That the hands of 
the milker be thoroughly washed before the operation of 
milking is commenced, and that after once being washed 
they be not again employed in handling the cow, other- 
wise than in the necessary operation of milking. Any 
such handling should be succeeded by another washing in 
fresh water before again commencing to milk. 4. That all 
milk-venders^ shops should be kept far cleaner than is 
often the case at present; that all milk-retailing shops 
should be compelled to provide proper storage accommo- 
dation, and that the counters, etc., should be tiled. 

* 

The Breed of a Cow. 

Some breeds yield quantity, others quality. Alder- 
neys and Jersey cows yield the most, by far. Short horns 
give the most casein and sugar; the average capacity of a 
cow's udder is about 5 pints, and the average annual yield 
of milk is about 600 gallons. 

Time and Stage of Milking. 

Cows are usually milked twice a day, the morning 
milk usually being larger in quantity and poorer in qual- 
ity. The milk which is first drawn is known as the fore- 
milk, and contains very much less fat than that last drawn, 
known as the strippings. This is due to a partial cream- 
ing taking place in the udders. Dishonest dealers have 
often taken advantage of this fact in adulteration cases to 



126 INFANT-FEEDING. 

have the cows partially milked in the presence of ignorant 
witnesses, the resulting milk consisting largely of the 
foremilk. 

Age of Cow. 

Young cows give less milk, while cows from four to 
seven years old give the richest milk, and less milk is 
given with the first calf. They give the largest yield, ac- 
cording to Fleishmann, after the fifth until the seventh 
calf; after the fourteenth calf they yield, as a rule, no 
more milk. The poorest milk is yielded during the spring 
and early summer; the richest during the autumn and 
early winter. If cows are worried or driven about, the 
quality and quantity of the milk is reduced. If they are 
kept warm and well fed, both quantity and quality is 
naturally increased. 

Effect of Alkalies on Milk. 

By running milk through a centrifugal machine a 
product known as ^^separator slime'^ is produced, which is 
analogous to mucin. A decided difi^erence in viscosity is 
noticed between milk before and after running it through 
a centrifugal machine. This ^^separator slime" swells up 
and forms a viscid jelly with lime-water or alkalies. Milk 
to which alkali is added is decidedly more viscous than 
milk that is slightly acid, and is so undoubtedly because 
of the action of the alkali on the mucin of the milk. 

Curdling of Milk and Diluents. 

Milk of all animals may be separated into two classes. 
Those that form a soft curd with rennet and those that 
form a hard curd with rennet. Woman^s milk is in the 
first class and cows^ milk in the second. 

The conditions favorable for the formation of hard 



albumi:n'oids in cows' milk. 127 

curds of cows' milk are body-heat and the presence of 
rennet and lactic or other acid. 

The rennet forms a clot of the milk^ the heat canses 
the lactic bacteria to grow in the curd, and the acid causes 
the curd to shrink and become leathery. Adding alkalies 
to the milk neutralizes the acid, but the bacteria will keep 
making more lactic acid as long as any sugar is present. 

Diluting milk with water does not prevent tough 
curds forming, but diluting with gruels does prevent the 
contraction of the curds. This has been proved beyond 
dispute, both experimentally and clinically. 

Albuminoids in Cows' Milk. 

That there are differences in the amounts of the albu- 
minoids occurring in human milk is proved by the fact 
that, while Professor Leeds found a variation of 0.85 to 
4.86, Professor Meiggs asserts that there was but 1 per cent. 

Konig, an earlier analyst, makes the variation from 
0.85 to 4.86. Some of these results give as high a per- 
centage of albuminoids in woman's milk as we find in 
cows' milk, and I have no doubt in my own mind that 
the time and habit of extracting the milk has a deal to do 
with the amount of occurring albuminoids. In other 
words, when milk is extracted every two hours or less, it 
cannot contain as much of the cell-material as milk from 
the same source extracted at intervals of twelve hours. 
This latter is riper and it is the non-uniformity of the tis- 
sue which causes all the difference in the different oc- 
curring albuminoids. We know that during the incuba- 
tion of eggs casein is developed from egg-albumin. This 
illustrates the ripening of albumin. Furthermore, take an 
egg just laid by the Ken, and boil it. and you will find im- 
mature albumin in it; that is, after boiling, instead of 



128 INFANT-FEEDING. 

being thick and finn^ like an older egg, much of it is milky. 
If boiled a few hours later, all the albumin will coagu- 
late perfectly, because it has had time to ripen. There is 
no doubt that the albuminoids in milk from healthy ani- 
mals are all cell-transformations, not an exudate, as are 
undoubtedly the fats and salts, because these latter we can 
influence by the food very plainly, but in health the al- 
buminoids are constant without regard to food, while dur- 
ing menstruation, pregnancy, and other conditions, nota- 
bly febrile disturbances, we find the fats and salts not 
materially afl^ected, but the albuminoids are decreased, in- 
creased, or totally changed, as we find in colostrum. The 
casein, besides lieing riper in oows' milh, by reason of its 
stronger growth, is intended by x^ature to coagulate into 
a hard mass, because it is the product of a cud-chewer for 
the nourishment of a cud-chewer, and the reason why it 
does not always coagulate in the infant's stomach as it 
does in that of the calf is that the latter animal's stomach 
secretes a principle called cliymosin; this is the principle 
that curdles cows' milk, and it operates either in an acid 
or an alkaline medium. Pepsin will not coagulate milk, 
and hence the hard coagulum of cows' milk that sometimes 
forms in the infant's stomach is due to acidity of that 
organ, and this acidity is not always the fault of the stom- 
ach, hut of the milk itself. The variations in the chemistry 
of the albuminoids found in cows' milk would not be sur- 
prising to anyone if he would examine into the condition 
of some of its mammary sources, for often it will be found, 
on dissecting a cow's udder, which I always do when mak- 
ing an autopsy on a cow, that there are old cicatrices, one 
or more quarters of the udder intensely inflamed, some- 
times a mammiferons dnct clogged with a calculus or a 
clot of fibrin, and, besides these pathological conditions, 



ALBUMINOIDS IN COWS' MILK. 129 

the mammary gland is subject to benign and malign infil- 
trations, bacillary tnbercnlar deposits, and ernptive dis- 
eases of the skin involving the gland and ducts; therefore, 
that fibrin, serum, and albumin, in various forms, are 
found in the cows^ milk is not surprising, and it can safely 
be assumed that any variation in the albuminoids from 
the normal casein can be ascribed to sickness on the part 
of the animal. 

We next come to the salts contained in milk, and it is 
remarkable how few analyses have been made to deter- 
mine the salts or minerals that are contained in this fluid. 
Heidlen^s analysis, copied everywhere, seems to be the 
only exhaustive one of the salines in cows' milk made dur- 
ing the present century. It seems to me in this case, too, 
that it is time for the chemist to teach us something more. 
There probably never was a time, in our era, at least, when 
milk was attracting so much attention as now, and still 
all our chemists are content with the total solids, fats, 
albuminoids and sugar — just what the butter-makers and 
cheese-makers want to know. From this much-quoted 
analysis of cows'-milk salts we learn that milk contains in 
various proportions the phosphates of lime, magnesia, and 
iron; the chlorides of potassium, sodium, and iron; and free 
soda. Eobin gets from human milk, in addition to the fore- 
going, carbonate of lime and soda, phosphate of soda, sul- 
phate of soda, and potash. We have no means of knowing 
how constant is the occurrence of any of these salts in milk 
or under what conditions they are modified; we do know, 
however, from the experiments of Fehling, that many of 
the drugs administered to the milking female are excreted 
irn the milk. Therefore, we can safely assume that the 
saline constituents occurring in milk are influenced both 
by the health and food of the animal. That the plios- 



130 INFANT-FEEDING. 

phates are craved for by the irdlhmg cow is evidenced by the 
habit of chewing old bones and the like, and that there is 
a lack of this element of food is not to he wondered at when 
we see her^ds of milMng cows pastured on old, worn-oiit 
lands; the practical farmer knows that exhausted pastnre- 
lands need, more than anything else for their rejuvenes- 
cence, the phosphates, and we know that in our nutrition 
we need them also. The land on which a cow is pastured 
will indicate pretty fairly what we may expect to find in 
her milk as salts. We have all noticed the excessive 
growth of sorrel on exhausted land, and can it then be a 
subject of wonder that some kind of a vegetable acid 
should be found in the milk of animals that are obliged 
to include this variety of food in their summer-rations 
and sour ensilage or spoiled brewery grains in their 
winter-feed? Theodore HankeFs discovery of citric acid 
in cows' milk to the amount of 0.9 and 1.1 grammes per 
litre is just what might be expected. 

Sugar, I think, in milk has always been overestimated 
as to its nutritive value, because we know that carnivorous 
animals do not secrete sugar to any appreciable extent, 
according to chemists. When we see a small slut nursing 
seven or eight puppies and keeping them all fat, and in a 
thriving condition, we can easily imagine that sugar is not 
a necessary element of food, for the canines excrete no 
sugar in their milk. We see that the gross result of con- 
densed-milk feeding with an excess of sugar is harmful. 
Brush maintains that pure cane-sugar is the ideal addition 
to cows' milk. 

Prof. L. B. Arnold, an authority on dairy matters, 
says that, when milk will not properly nourish an infant, 
then it is not the cows' milk that is at fault, but it is 
either a pathological condition of the cow or improper 



ALBUMINOIDS IK COWS' MILK. 131 

food or care, or the conditions through which the milk has 
passed on its wa}' from the cow to the infant. 

The average temperature of a cow is 102 V2° F. 
(Brush). This is certainly a peculiarity of the cow. An- 
other peculiarity is the constant employment of her gen- 
erative functions: she is always milking or pregnant, and 
hoth the uterus and the mammary glands are employed al- 
most constantly at the same time. Her nervous system is 
more subject to severe shocks, and she is a delicate creat- 
ure. If we consider the average income from a cow, it is 
about $20.00 a year to the producer. This is about 7 cents 
a day, from which the dairyman has to buy food and pay 
for labor. In order to make a profit the dairyman must 
utilize every drop of milk, whether the animal giving it be 
sick or well. It is, therefore, very common to find all the 
cheap foods, such as brewery grains, distillery slops, and 
the refuse from starch-factories enter largely into the 
food from which our babies' supply of milk is produced. 
Brush maintains that, in personal inspections of small 
dairies near 'New York City, the sole article of diet was 
swill. One of the means employed for removing the stable 
odors of milk is by adding nitrate of potash, commonly 
known as "saltpeter.'' With this drug a substance re- 
sembling nitroglycerin is formed. It is strange that the 
toxic effects of nitroglycerin are similar to those of tyro- 
toxicon. 

Brush believes that the ideal dairy for supplying in- 
fant-food should be composed entirely of spayed cows, 
and thus one constant source of nervous function of dis- 
turbance would be eliminated. He believes that these 
animals are much more quiet in disposition, they give a 
more constant and uniform supply of milk, and seem to 
enjoy a more even degree of health than the cow who is 



132 INFANT-FEEDING. 

occasionally bulling and becoming pregnant when giving 
milk. The author has certainly had very good results 
with Brush's milk^ and, although it is somewhat expensive, 
he has found it well adapted for the home-modification of 
infants' food. 



CHAPTER XVIT. 

Cream. 

AVhex food contains too little fat, or its equivalent 
(cream), we have fat-starvation, which is soon manifestefl 
by symptoms of rickets. One of the earliest S3'mptoms of 
rickets is constipation, showing deficient niuscnlar tone: 
a distinct atony of the bowel. 

This can be remedied by the addition of fat or cream 
to the food. Some children are benefited by giving them 
codliver-oil, butter, or olive-oil. Some authors advise 
giving fried bacon to very young children; thus it is plain 
that each one desires to remedy the deficiency of fat in 
his own manner. 

In buying cream from small milk-stores one can make 
a rough guess at the proportion of fat in cream by its 
thickness. A 50-per-cent. cream at the ordinary tempera- 
ture of the room runs from a jug slowly and in a thick 
stream, almost like thick mucilage, whereas a 16-per-cent. 
cream runs almost as freely as milk. This is, however, 
a crude way of estimating the difference between poor and 
rich cream. It is a very important ])oint to know exactly 
what percentage of cream we are using, for such mixtures 
like Biedert's, in which 1 ounce of cream is mixed with 
3 ounces, of water, may agree very well when we use a 
16- or 20-per-cent. cream, but might be disastrous if we 
used a cream containing 40 per cent, of fat. Such infants 
would not tolerate this rich cream, but might have 
troublesome vomiting. 

(133) 



134 INFANT-FEEDING. 

CEEAM FOR HOME-MODIFICATION. 

Ordinary Cream. — This is made by setting milk at 
night and skimming it in the morning; it is called grav- 
ity, or skimmed, cream, and contains 16 per cent, of fat. 

Twelve-pe7'-cent. Crecwi. — Obtained in the city by 
using equal parts of ordinary (20 per cent.) centrifu- 
gal cream and plain milk. In the country we must use 
2 parts of ordinary skimmed, or gravity, cream (16 per 
cent.) with 1 part of plain milk, or by taking the top layer 
of milk after standing five or six hours, by means of 
siphoning. 

Eiglit-per-cent. cream is obtained in the city by dilut- 
ing 1 part of centrifugal (20 per cent.) cream with 3 parts 
of plain milk; in the country, by using 1 part of gravity 
cream and 2 parts of plain milk, or by using the top layer 
of milk after standing five or six hours and siphoning 
it off. 

Top-milh is obtained directly from fresh milk by the 
so-called "gravity process.^^ Cream contains a great deal 
of fat, usually three-fifths of cream is fat; this floats 
on the surface of the watery milk. If a quart bottle of 
the average city milk is put into ice-water or upon ice in 
the refrigerator, and removed after four or five hours, we 
can skim off from the top about 10 ounces of an 8-per- 
cent, cream; after six hours about 6 ounces of 12-per-cent. 
cream. This I shall speak of as top-milk. Frequently, 
instead of skimming the cream, the lower portion is si- 
phoned off, leaving the cream in the glass bottle. When 
cream is removed by a centrifugal machine, it is known 
as centrifugal cream. It can be separated much quicker 
from milk than milk which must stand and rise naturally 
(slow process): so-called gravity cream. 



ORE AM. 135 

HOW TO PROCURE CREAM. 

Set aside the ordinary quart bottle of milk on the ice 
for several hours (from six to eight hours) to allow the 
cream to rise. Draw the milk after the cream has risen 
from the bottom of the bottle; this can be accomplished 
by means of a siphon. 

To make the siphon get a piece of glass tubing 21 
inches in length and a quarter of an inch in calibre. This 
can be procured in every drug-store. German glass is less 
liable to crack than American glass. If the glass tubing 
is longer than 21 inches make a small scratch in it^ after 
measuring off 21 inches, with a three-cornered file; then 
catch the glass tubing between the fingers and opposing 
thumbs of both hands, having the thumb-nails touching 
on the side of the glass just opposite to the scratch. On 
attempting to bend the glass tube it will break smoothly 
across, and if there are any sharp edges they can be 
smoothed by rubbing them down with the file. 

To bend the glass tube to the V shape, hold it in the 
flame of an ordinary gas-jet or alcohol-lamp for a few 
moments, twirling the glass rod until it softens suffi- 
ciently to allow it to be bent to the required angle. The 
tube should be warmed gradually at first, and then put 
right into the flame. It is better in bending the glass to 
make one arm of the siphon a few inches longer than the 
other. 

In using the siphon hold it with the angle down, fill 
it with water and close the long arm with the tip of the 
finger, then keeping the finger applied to the long end, 
turn the siphon with the angle up, and introduce the short 
arm into the bottle of milk, letting it rest upon the bot- 
tom. On removing the finger, the milk will flow through 



136 INFANT-FEEDING. 

the tube^ and. continue to do so until the bottle is empty. 
It is, therefore, necessary to watch the layer of cream, so 
that the siphon can be lifted out of the bottle just before 
the cream reaches it, and thus remain in the milk-bottle 
all of the cream and a small portion of the milk, the latter 
depending upon the expertness of the person using the 
siphon. 

TO PASTEURIZE THE CEEAM. 

Take a clear glass bottle not having the neck very wide; 
fit a perforated cork into the same having a chemical ther- 
mometer registering up to 212° F. The bulb of the ther- 
mometer should come within half an inch of the bottom 
of the bottle. The cream is put into the bottle, and the 
cork containing the thermometer is inserted; the bottle 
is then placed in a pot containing a couple of inches of 
warm water and. allowed to heat on the stove. The ther- 
mometer should be watched until it reaches 160, taking 
care that it does not go above 170. When the ther- 
mometer has reached this point, set the pot back on the 
stove where it will cool off, and allow it to remain there 
for twenty minutes. At the end of this time substitute a 
plug of absorbent cotton for the cork containing the ther- 
mometer. Great care must be taken to keep the absorbent 
cotton dry. Cream thus prepared is pasteurized, and will 
keep sweet and fresh for twenty-four hours without being 
kept on ice, and all that is necessary in removing a portion 
from the bottle is to be. sure that the cotton plug does not 
become moist, or, if it should, to replace it with a dry piece 
at once. 

TO GLEAN THE GLASS SIPHON. 

It is advised immediately to fill it with water after 
using it, and the ordinary tube-brush having eighteen 



MODIFICATION OF MILK. 137 

inches of vrire added to it will lengthen the same and per- 
mit thorongh cleansing. Nothing, however^ will be found 
as good as thorough boiling in plain water to which 
a pinch of soda has been added. 

M0J)IFICATI0N OF MiLK. 

It has been shown previously that the percentages 
of fat in woman's and cows' milk are about the same^ that 
the quantity of sugar is rather lower in cows' milk, and 
that the quantity of casein and albumin is greater in cows' 
milk, as is also that of the ash. Experience has shown 
that cows' milk must be diluted before it can safely be 
fed to infants. Simply diluting the milk reduces the per- 
centages of fat and sugar too much; so the practice of 
adding cream and sugar has arisen, but the processes that 
have been advocated for obtaining the desired additional 
quantities of fat and sugar have been too complicated for 
general use. 

The top 9 ounces of a quart of milk on which the 
cream has risen will be about three times as rich in fat 
as the whole milk, the top 15 or 16 ounces will be about 
twice as rich as the whole milk, while the other ingredi- 
ents remain about the same as in whole milk. 

For babies under 3 months of age the top 9 ounces 
of a quart of milk on which the cream has risen should 
be diluted from 3 to 10 times and 1 part of sugar added 
to 25 parts of food. 

For babies 3 to 6 months old the top 16 ounces of a 
quart of milk on which the cream has risen should be di- 
luted 2 or 3 times and 1 part of sugar added to 25 or 30 
parts of food. 

For babies 6 to 9 months old the top 20 ounces of a 
({iiart of milk on which the cream has risen should be di- 



138 



INFANT-FEEDING. 



luted V2 "to 1 "ti^Le and 1 part of sugar added to 50 parts 
of food. An even tablespoonful of granulated sugar 
equals '^/^ ounce. 

By following this method the infant commences on 
weak mixtures that show about the same composition and 
variations as mothers' milk and gradually takes food 
richer in casein nntil plain milk is reached. 

The dilnents used are water^ gruels, or dextrirdzed 
gruels, which are simply ordinary gruels the starch of 
which has been converted into soluble forms, leaving the 
cellulose and proteids of the cereal in a finely-divided 
state. The effect of the different diluents will be men- 
tioned farther on. 



Milk-sugar Solutions. 

1. Take 1 ounce of milk-sugar and 20 ounces 1 

of water, and dissolve. | 

Or 1 even tablespoonful of milk-sugar and )• 

7 ^/z tablespoonfuls of water, and dis- | 

solve. J 

2. Dissolve 1 tablespoonful of milk-sugar in ] 

6 V2 ounces of water. { 

Or 1 ounce of sugar is to be dissolved in | 

16 V2 ounces of water. J 



This makes about a 
5-per-cent. sugar 
solution. 



Makes a 6-per-cent. 
sugar solution. 



3. Dissolve 1 ounce of sugar in 14 ounces of 

water. 
Or 1 even tablespoonful in 5 ^/j ounces of 

water. 



Makes a 7-per-cent. 
sugar solution. 



4, Dissolve 1 ounce of sugar in 12 V2 ounces 

of water. 
Or 1 even tablespoonful in 12 V2 ounces of 
water. J 

5. Double the strength of above milk-sugar f 

(Formula No. 1). \ 



Makes an 8-per- 
cent, sugar solu- 
tion. 

Makes a 10-per- 
cent, sugar solu- 
tion. 



MODIFICATION OF MILK. 139 

ADDITION OF SUGAR TO MILK. 

In order to render milk palatable, sugar must be 
added in some form; hence cane-sugar or milk-sugar has 
been advised. Jacobi insists on the addition of cane- 
suo-ar, and he agrees with Biedert, who uses it in his 
cream-mixture. That cane-sngar certainly has some 
virtue can be seen by the fact that it is used extensively 
as a preservative in the manufacture of condensed milk. 

Cane-sugar. — Cane-sugar^ being far sweeter than 
sugar of milk, it is advisable to use ^/o the quantity that 
would ordinarily be used for sweetening with milk-sugar. 
Cane-sugar is advised in the treatment of constipation; 
frequently we find breast-fed babies who suffer constipa-. 
tion, the cause of which is deficiency in sugar. In such 
eases giving '^/^ lump or about '^/^ teaspoonful of cane- 
sugar dissolved in a teaspoonful of sterile water (ordinary 
boiled water), and this given immediately before putting 
the baby to the breast, will make up the deficient sugar 
and frequently modify a distressing constipation without 
resorting to drugs. 

Contra-indications to the Use of Sugar. — There are a 
great many conditions in which the additioDi of sugar is 
not only contra-indicated, but absolutely harmful. For 
example: If an infant suffers with colic and has sudden 
attacks (paroxysms) of pain which disturb the infantas 
sleep, such an infant will be found with its legs drawn up to 
its belly, and besides it will utter shrieks while crying. The 
stools will be usually green and sour smelling, and the ab- 
domen will be found greatly distended with gas from fer- 
mentation, and frequently the infant will have violent 
eructations. Such an infant usually receives an excess of 
sugar. The treatment of such a case is the absolute dis- 
continuance of sugar in the food. 



140 INFANT-FEEDING. 



HOW SHALL WE SWEETEN 



I 



If constipation has accompanied the infant's fer- 
mentative condition and has also preceded this attack of 
colic, then I advise adding glycerin to the milk. It has a 
very sweet taste and a decided laxative effect. 

Dose of Glycerin. — For some children half a teaspoon- 
fnl of glycerin added to each bottle will snffice; for others, 
I frequently nse 1 teaspoonful to each bottle, rarely more. 
Ulycerin has a decided antifermentative effect; being an 
oil, it is indicated in children requiring the addition 'of 
fat. It certainly has decided nutritive properties. 

SOLUTIONS USED FOR RENDERING COWS' MILK 
ALKALINE. 

Lime-water is the alkali usually selected for neutral- 
izing the acidity in cows' milk. It acts by partly neutral- 
izing the acid of the gastric juice, so that the casein is 
coagulated graclually and in small masses, or passes, in 
great part, unchanged into the intestine, to be there di- 
gested by the alkaline secretions. As it contains only Vg 
grain of lime to the fluidounce, the desired result cannot 
be attained unless at least a third part of the milk- 
mixture be lime-water. Instead of lime-water, 2 to 4 
grains of bicarbonate of sodium may be added to each 
bottle, or, better still, from 5 to 15 drops of the saccha- 
rated solution of lime. 

This solution is made in the following way: — 

IJ Slaked lime, 1 ounce. 

Refined sugar, in powder, 2 ounces. 
Distilled water, 1 pint. 

Mix the lime and sugar by trituration in a mortar. 
Transfer the mixture to a bottle containino: the water, 



I 



MODIFICATION OF MILK. 141 

aiid^ having closed this with a cork^ shake it occasionally 
for a few hours. Finally separate the clear solution with 
a siphon and keep it in a stoppered bottle. 

Bicarhonate-of-Soda S'olution (Baking -so da). — Take 1 
grain of soda bicarbonate to ^/o ounce of water. Or 1 
drachm of soda bicarbonate to 1 quart of water. This is 
the proper strength used for diluting milk. 

Quantity to he Used. — One tablespoonful of the last- 
named solution equals in strength 1 tablespoonful of ordi- 
nary lime-water. 

Both lime-water and soda-bicarbonate solution 
should be kept in a very clean, well-stoppered bottle and 
in a cool place. 



CHAPTEK XVIII. 



Water. 



Of all the necessities of an infant, water stands out 
most prominently. It will aid materially in clearing the 
mouth and gums and quench the thirst. It is certainly 
diuretic, and water given regularly is one of our best laxa- 
tives. It is a good rule, and one that I insist upon, namely: 
to instruct every mother and nurse that a child, young or 
old, must receive water several times a day. 

Quantity. — An infant up to the first month shall re- 
ceive several teaspoonfuls of plain sterile (boiled) water, 
which has been allowed to cool, but by no means ice-water. 

This drink of water is best given either immediately 
after nursing or feeding or as soon after the feeding as 
possible. 

It is not necessary to awaken the child to give it a 
drink, but if it is not time for feeding and the infant is 
restless, a few spoonfuls of cool water will frequently com- 
fort it. 

When we desire to modify constipation, then water 
will be a most important factor, especially so when large, 
cheesy curds are found in the stool. 

Instances will be found in which some children will 
refuse water; then the slightest addition of a few grains 
of granulated (cane-) sugar will prove advantageous. 
Older children, over six months old, can, if properly de- 
veloped, take hold of a glass and be guided in the drinking 
or sipping of a wineglassful of water. I advise giving at 
least 3 wineglassfuls of plain sterile (boiled) water per day, 
especially during warm weather. 

(148) 



WATEK, 143 

The free dilution of children's nourishment with 
water is demanded upon the following additional facts: 
Only to a certain limit will pepsin be furnished for di- 
gestive purposes. Probably a portion of this is not en- 
tirely utilized. A great quantity of water is necessary to 
assist in pepsin digestion. In artificial digestion albumin 
often remains unchanged until large quantities of acidu- 
lated water are supplied. Without doubt many disturb- 
ances of digestion are to be explained by a deficiency of 
water^ certainly many more than are due to an excess of 
it, as it is so quickly absorbed. 



CHAPTER XIX. 

Bottle-feeding^ or Hand-feeding. 

CleanUness. — The most important point to remember 
is that everything used in connection with "hand-feeding'' 
must be scrupulously clean. 

To sterilize milk in a filthy bottle, or to put milk 
contaminated with stable filth or dirt from the udder of 
a cow, or milk containing pathogenic bacteria, into an abso- 
lutely-clean bottle, is surely repulsive. 

Therefore, my first proposition is: '^clean every- 
thing that is associated with infant-feeding/' from the 
milking of the cow, the surroundings of the cow, until the 
food is ready to be fed to our infants. This necessarily 
implies quite an amount of work, which I shall try to 
detail later on. 

Amount to he Fed. — Ssnitkin (investigations at the 
Children's Hospital of St. Petersburg, quoted by Eotch) 
makes the following rule: "The greater the weight, the 
greater the gastric capacity." 

Ssnitkin's table of calculation shows that one one- 
hundredth of the initial weight should be taken as the 
figure with which to begin the computation, and to this 
should be added one gramme for each day of life. 



Initial 
Weight. 

:3000Gm. 
4500 Gm. 

6000 Gm. 
(144) 



Illustration of Ssnitkin's E.ule. 

Earli/ Bat/s. At 15 Days. At SO Bays. 

30 Gni . 30 + 15 z=^ 45 (Jni . 30 + 30 = 60 Gm . 

(About loz.) (About 1^ oz.) (About 2 oz.) 

45 Gm . 45 + 15 == 60 Gm . 45 + 30 = 75 Gra . 

( About 1^ oz. ) ( About 2 oz. ) ( About 2 J oz. ) 

60 Gm . 60 4- 15 = 75 Gm . 60 + 30 = 90 Gm . 

( About 2 oz. ) ( About 21 oz. ) ( About 3 oz. ) 



CHAPTEE XX. 



Feeding-table and Cream-mixtures. 



Age. 


Intervals 
OF Feeding. 


Number 
OF Times 

IN 

24 Hours. 


Average 
Amount 

Each 
Feeding. 


Average in 
24 Hours. 


1st week .... 
1st month . , . 
2d month . . 
3d and 4th mos. 
5th and 6th mos. 


2 hours 

2 hours 
2.} hours 

3 hours 
3 hours 


10 

8 
8 
7 
6 


loz. 
li to 2 oz. 

3 to 4 oz. 

4 to 5 oz. 
6 to 7 oz. 


10 oz. 
12 to 16 oz. 
20 to 30 oz. 
30 to 35 oz. 
34 to 40 oz. 



The above is the feeding-table of George C. Car- 
penter (London). 

biedert^s cream-mixtures. 

The following formiilse are from the fourth edition of 
his book on "Infant-feeding/^ published in 1900: — 



Formula. Cream. 


Water. 


3Tilk-sugar. 


31ill\ Casein. 


Fat. 


Sugar. 










Per Cent. 


Per Cent. 


Per Cent. 




I. 4 oz. 


12 oz. 


4Mr. 




0.9 


2.5 


5 




II. 4 oz. 


12 oz. 


4* dr. 


2oz. 


1.2 


2.6 


5 




III. 4 oz. 


12 oz. 


4:^ dr. 


4 oz. 


1.4 


2.7 


5 




IV. 4 oz. 


12 oz. 


4* dr. 


8 oz. 


1.7 


2.9 


5 




V. 4 oz. 


12 oz. 


4Jdr. 


12 oz. 


2.0 


3.0 


5 




VI. 


8 oz. 


3 dr. 


24 oz. 


2.5 


2.7 


5 




Cream 


Milk. 


Water. ^^^- 
sugar 


Casein. 


Fat. 


Sugar. 








Per Cent. 


Per Cent. 


Per Cent. 


1. 


1st mo. ^iv. 


No. 


|xij. ^ss. 


Is equiv- 
alent to 


1.0 


2.4 


3.8 


2. 


2d mo. No. 


.^ij- 


No. No. 


Is equiv- 
alent to 


1.4 


2.6 


3.8 


3. 


3d mo. Xo. 


.liv. 


No. No. 


Is equiv- 
alent to 


1.8 


2.7 


3.8 


4. 


4th mo. No. 


I^iij. 


No. No. 


Is equiv- 
alent to 


2.3 


2.9 


3.8 


5. 


5th mo. No. 


3xij. 


No. No. 


Is equiv- 
alent to 


2.6 


• 3.0 


3.7 


6. 


6th mo. No. 


.^xvj. 


,^viij. .^iiss. 


Is equiv- 
alent to 


3.2 


3.0 


4.0 








10 






(145) 



146 INFANT-FEEDING. 

The latter are known as Biedert^s cream-mixtures, 
and are quoted by A. Jacobi.^^ 

According to recent milk-analyses, it is necessary to 
take 6 per cent., which is equivalent to 5 ^/g drachms of 
sugar, to 12 ounces of water. It has also been shown that 
cane-sugar in the same quantity as milk-sugar can be used. 
In using Formula 5, especially if an infant is constipated, 
it is advisable gradually to substitute milk for the water; 
thus we take away 1 ounce of water, and add 1 ounce of 
milk, until our formula is: — 

Cream. Sugar-water. Milk. 

4 ounces. 4 ounces. 20 ounces. 

and gradually arrive at a whole-milk feeding; in other 
words: give pure cows' milk undiluted. Biedert claims 
that frequently diluted cows' milk was not well borne, 
especially on weak stomachs, and the change to the cream- 
mixture resulted in decided benefit. Moreover, he believes 
that the cream-mixture is assimilated far better than the 
diluted milk-mixtures not containing cream. 

Thus he claims that those cases of constipation alter- 
nating with diarrhoea and lastly mucous enteritis are 
those in which the cream-mixture will render satisfaction; 
but he advises that a definite rule must prevail regarding 
the amount of fat contained in the cream, and he advises 
that an 8- to lO-per-cent. cream be used. 

biedert's directions for making his cream. 

From 1 to 2 quarts of milk are put into a broad jar 
(glass) on the ice, for no longer than two hours. He then 
removes with a flat spoon from 3 ^/^ to 7 ounces of the 



"Therapeutics of Infancy and Childhood. 



1 



biedert's cream-mixtures. 147 

thin white creamy layer over the bluish mass of milk. In 
removing the above quantity a small portion of the milk 
will be removed with it. In cases of severe constipation 
Biedert insists on removing pure cream. 

The above Formula I is for the first month, Formula 
II is for the second month, Formula III is for a child from 
three to four months, Formula IV is for fourth to fifth 
month. Formula V is for the sixth to seventh month, and 
Formula YI is for the eighth to tenth month. 

It is self-understood that, while feeding, the general 
condition of the child is the criterion, and thus we will 
frequently be compelled to change the formula for indi- 
vidual requirements, some infants requiring far more 
cream than the above-mentioned formulae give them for 
their age and their weight, whereas the great majority 
will require a modification of far less cream than the 
above-given formulae for their age and weight. 



L 



CHAPTER XXI. 
Home-modification of Milk. 

coit's decimal method (tuttle^ gallaudet). 

This is the simplest and easiest-worked method of 
home-modiiication yet suggested. It is based on the 
metric system^ and all the calculations are made in deci- 
mals. 

Three solutions are required: 1. A decimal (10 per 
cent.) cream, or sujoerfatted milk for introducing the fat. 
2. A saccharated (10 per cent.) skimmed milk for intro- 
ducing proteids not carried by the cream. 3. A standard 
(10 per cent.) sugar solution for introducing the lactose 
not carried by the cream or the skimmed milk. Solutions 
1 and 3 only are required when the proteid percentage is 
small. .As the child grows older, and a higher proteid 
percentage is necessary, solution 2 is required also. 

Decimal cream is produced by allowing a quart of 
ordinary fresh milk from a mixed herd to stand on ice for 
fifteen hours, and at the end of this time one-fifth of it is 
taken from the top. This averages 15 per cent, of fat, 
and loses about ^/^ per cent, each of sugar and proteids. 
If to this we add ^/^ its volume of water, a decimal cream 
is obtained, analyzing: 10 per cent, of fat, 2.33 per cent, 
of proteids, and 2.66 per cent, of sugar. From this the 
following formulae, showing the amounts of proteids and 
lactose coincidently introduced with any definite fat-per- 
centage, are easily deduced: — 

Decimal cream in introducing 4 per cent, of fat also 
introduces 1 per cent, of proteids and 1 per cent, of lac- 

(148) 



HOME-MODIFICATIOX OF MILK. 1^1:9 

tose. Decimal cream in introducing 3.5 per cent, of fat 
also introduces 0.8 per cent, of proteids and 0.9 per cent, 
of lactose. Decimal cream in introducing 3 per cent, of 
fat also introduces O.T per cent, of proteids and 0.8 per 
cent, of lactose. Decimal cream in introducing 2.5 per 
cent, of fat also introduces 0.6 per cent, of proteids and 
0.7 per cent, of lactose. Decimal cream in introducing 2 
per cent, of fat also introduces 0.5 per cent, of proteids 
and 0.5 per cent, of lactose. 

Saccliarated skimmed milli depends on the fact that 
skimmed milk analyzes i per cent, of proteids and 5 per 
cent, of sugar. Five per cent, more of lactose is added 
simply for convenience of calculation. This means adding 
1 ormce, by weighty of lactose to 20 ounces of skimmed 
milk. Our solution then analyzes: proteids, 4: per cent.; 
and lactose, 10 per cent. If we wish to add 1 per cent, of 
proteids, we use one-fourth of the total food required from 
solution 2; if 0.5 per cent, of proteids, one-eighth, etc., 
always remembering that we introduce coincidently two 
and one-half times as much sugar. The formula here de- 
duced are also 23lain: — 

Amount of food in cubic centimetres x ^/g (sacclia- 
rated skimmed milk) adds proteids, 0.5 per cent.; and lac- 
tose, 1.25 per cent. Amount of food in cubic centimetres 
X ^/^ (saccharated skimmed milk) adds proteids. 1 per 
cent.; and lactose, 2.5 per cent. Amount of food in cubic 
centimetres x Yg (saccharated skimmed milk) adds pro- 
teids, 1.5 per cent.; and lactose, 3.75 per cent. Amount 
of food in cubic centimetres x ^/^ (saccharated skimmed 
milk) adds proteids, 2 per cent.; and lactose, 5 per cent. 

Standard sugar solution is prepared by dissolving 10 
per cent, of lactose in sterile water, or 2 ounces, by weight, 
in 20 ounces of water. 



% 

150 INEANT-FEEDING. 

In calculating formulae four facts only are necessary: 
the quantity of food required; the percentage-formulae 
required; that the standards, except the proteids, are 10 
per cent.; and the quantity of other constituents intro- 
duced with the standards. 

With these facts in mind, all that is necessary further 
is to reduce the quantity expressed in ounces to cubic 
centimetres by multiplying by thirty, and to multiply this 
product by one-tenth of the constituent to be introduced. 
Examples with and without the introduction of extra pro- 
teids will be given: — 

Single Feeding. 

Fat. Proteids. Sugar. 

Percent. Per Cent. Per Cent. 

Quantity, 2 oz. Formula desired 2.0 0.50 6.00 

Oz. 2X30 = 60 corns. X 0.2 = 12 c.cms. 
decimal cream, adds 2.0 0.50 0.50 

Leaves 0.0 0.00 5.50 

Oz. 2X30 = 60 c.cms. X 0.55 = 33 c.cms. 

sugar solutioD, adds 5.50 

Working formula: 12 c.cms. decimal cream. 

33 c.cms. standard sugar solution. 
15 c.cms. water. 

60 c.cms. 

One Day's Food. 

Fat. Proteids. Sugar. 

Per Cent. Per Cent. Per Cent. 

Quantity, 35 oz. Formula desired 4.0 1.0 6.50 

Oz. 35 X 30=1050 c.cms. X 0.4 = 420 c.cms. 

decimal cream, adds . , 4.0 1.0 1.00 

Leaves 0.0 0.0 5.50 

Oz. 35 X 30 = 1050 c.cms. X 0.55 = 577.50 
c.cms. sugar solution, adds 5.50 

AVorking formula: 420.00 c.cms. decimal cream. 

577.50 c.cms. standard sugar solution. 
52.50 c.cms. water. 

1050.00 c.cms. 



HOME-MODIFICATION OF MILK. 



151 



One Feeding. 

Fat. Proteids. Sugar. 

Per Ceat. Per Cent. Per Cent. 

Quantity, 5 oz. Formula desired 4.0 1.50 7.00 

Oz. 5X30 = 150 c.cms. X 0.4 = 60 c.cms. 

decimal cream, adds . 4.0 1.00 1.00 

Leaves 0.0 0.50 6.00 

Oz. 5 X 30 = 150 c.cms. X i = 18.75 c.cms. 

skimmed milk, adds 0.0 0.50 1.25 

Leaves . . . ....... 0.0 0.00 4.75 

Oz. 5 X 30 = 150 c.cms. X 0.475 = 71.75 
c.cms. sugar solution, adds 4.75 

Working formula: 60.00 c.cms. decimal cream. 

18.75 c.cms saccharated skimmed milk. 
71.25 c.cms. standard sugar solution. 

150.00 c.cms. 



Geneeal Eules for Bottle-feeding. 



Age OF 

CHIL.D. 


Frequency 
OR Inter VAL, 
OF Feeding. 


Number of 

Feedings in 

21 Hours. 


Average 

Amount for 

Each 

Feeding. 


Average 
Amount in 
24 Hours. 


From its 

birth until it 

is 1 month 

old. 


2 hours. 


10 


1 ounce. 


10 ounces. 


1 month 

until 
2 months. 


Every 
2 J hours. 


8 


1^ some- 
times 
2 ounces. 


From 12 to 
16 ounces. 


2 to 4 Every 
months old. 3 hours. 


6 or 7 


From 
3 to 4 ounces. 


From 18 to 
24 ounces. 


4 to 6 
months old. 


Every 
3 hours. 


6 


5 or 6 ounces. 


30 or 36 
ounces. 


6 to 9 
months old. 


Every 3} to 
4 hours. 


5 


8 ounces. 


40 ounces. 


9 to 12 
months old. 


Every 
4 hours. 


5 


8 ounces. 


40 ounces. 



152 INFANT-FEEDING. 

EuLES FOR Feeding. 

F'Or a Child at Birth. Formula 1. — The newborn in- 
fantas food should consist of: — 

Home-modifiGation. 
To make this formula, we take of 

Fat 1.0 Cream 2 ounces. 

Sugar 5.0 Milk 2 ounces. 

Proteids 0.75 Lime-water 1 ounce. 

Reaction alkaline. Water 15 ounces. 

Milk-sugar 6 V4 drachms. 

The above formula (1) is to be divided into 10 feed- 
ings of 1 ounce each, or 30 cubic centimetres each, and 
should be heated for 20 minutes to 167° F. 

The cream must contain at least 10 per cent, of fat. 
This is known as a decimal cream, and can be referred to 
under the heading of "Cream for Home-modification.^^ 

Child 1 Month. Formula 2. — 

Formula for Home Use. 
Take of 

Fat 2.0 Cream 4 ounces. 

Sugar 5.0 Lime-water 1 ounce. 

Proteids 0.75 Water . 15 ounces. 

Lime-water . .5.0 Milk-sugar 6V4 drachms. 

The above quantity is to be divided into ten feedings, 
and heated for 20 minutes to 167° F., and the infant to be 
fed once every two hours. In Formula 2 we have added 
more cream and purposely left out the milk. If the in- 
fant thrives on this mixture, then we can substitute 1 
ounce of milk instead of 1 ounce of water. 

After the end of the second month the quantity of 
food can be increased if the infant's appetite, sleep, stools, 
and general condition warrant it. Thus, instead of feed- 



EFFECT OF HEATING MILK. 153 

ing a bottle of Formula 2, we simply add 1 ounce of milk 
for the third month to Formula 2. 

At 4 Months. Foi^mula 3. — 

Formula for Home Use. 
Take of 

Fat 3.5 Cream 7 ounces. 

Sugar 6.5 Milk 1 ounce. 

Proteids 1.5 Lime-water 1 ounce. 

Lime-water . .5.0 Water 11 ounces. 

Milk-sugar 67* drachms. 

Divide into eight bottles; heat as above to 167° F.: 
feed every three hours. 

Froni 9 to 12 Months. Formula 4. — 

Formula for Home Use. 

Fat 4.0 Cream 8 ounces. 

Sugar 7.0 Milk 7 V2 ounces. 

Proteids .... .3.0 Lime-water 1 ounce. 

Lime-water . . 5.0 Water 3 V2 ounces. 

Milk-sugar 6V4 drachms. 

The above to be divided into five feedings, heated to 
167° F., and one bottle fed every four hours. 

Schedule for feeding an average healthy infant from 
birth upon modified cows' milk, showing percentages of 
fat, sugar, and proteids, and the daily quantity (Holt), see 
tables on page 154. . 

Effect of Heating Milk. 

Pasteurizing and sterilizing are still necessary evils. 
They are really more useful in keeping milk from spoil- 
ing than for any other purpose. The diseases transmitted 
by milk are very few, and are almost invariably due to 
contaminated water and utensils, and should be obviated 



154 



INFANT-FEEDING. 



d 


< 


Fat. 
Per Cent. ] 




1 
Proteids. \ 
Percent. 


si 


It 
< < 


I. 


1st and 2d day. 




5.0 




4-8 


125-250 


II. 


3d to 7th day. 


2.0 


6.0 


0.60 


10-15 


310-460 


III. 


2 to 4 weeks. 


2.5 


6.0 


0.80 


20-30 


620-930 


IV. 


1 to 3 months. 


3.0 


6.0 


1.00 


22-36 


680-1110 


V. 


3 to 4 months. 


3.5 


6.0 


1.25 


28-38 


870-1180 


VI. 


4 to 6 months. 


4.0 


6.0 


1.50 


32-38 


990-1180 


VII. 


6 to 9 months. 


4.0 


7.0 


2.00 


34-42 


1050-1300 


VIII. 


9 to 12 months. 


4.0 


6.0 


2.50 


38-45 


1180-1400 


IX. 


12 to 15 months. 


4.0 


5.0 


3.00 


40-50 


1240-1550 


X. 


15 to 18 months. 


4.0 


5.0 


3.50 


45-50 


1400-1550 


XI. 


18 months 














^ (whole milk). 


3.5 


4.3 


4.00 


45-50 


1400-1550 



FoEMUL^ Obtained by Diluting 12-per-cent. Cream. 



Dil 
Dil 
Dil 
Dil 



5 times with 6-per-cent. sugar sol. : 
4 times with 6-per-eent. sugar sol. : 
3 times with 7-per-cent. sugar sol.: 
2J times wibh 7-per-cent. sugar sol. : 
Dil. 2 times with 7-per-cent. sugar sol. : 

By diluting five times is meant one part of the cream and fi^•e 
parts cff the sugar solution, etc. 





Fat. 


Suqar. 


Proteids 




Per Cent 


Per Ceat. 


Per Cent 


II. 


2.0 


6 


0.60 


III. 


2.5 


6 


0.80 


IV. 


3.0 


6 


1.00 


V. 


3.5 


6 


1.20 


VI. 


4.0 


6 


1.30 



FoEMULiE Obtained by Diluting 8-pee-cent. Cream. 



Dil. once with 10-per-cent. sugar sol. 
Dil. Ij times with 7-per-cent. sugar sol. : 
Dil. 3 times with 7-per-cent. sugar sol. : 
Dil. 7 times with 5-per-cent. sugar sol.: 





Fat. 


Sugar. 


Froteid.<. 




Per Cent 


Per Cent. 


Per Cent 


VII. 


4 


7 


2.00 


XII. 


3 


6 


1.50 


XIII. 


2 


6 


1.00 


XIV. 


1 


5 


0.50 



Formulae Obtained by Diluting Plain Milk. 

Fat. Sugar. Proteid.'< 

Per Cent. Per Cent. Per Cent. 

Dil. once with 8-per-cent. sugar sol.: XV. 1.80 6 2.00 

Dil. 3 times with 5-per-cent. sugar sol.: XVI. 0.90 5 1.00 

Dil. 7 times with 4-per-3ent. sugar sol.: XVII. 0.45 4 0.50 

Dil. 11 times with 4-per-cent. sugar sol.: XVIII. 0.30 4 0.34 



CHANGES IN MILK CAUSED BY STERILIZATION. 155 

by dairy inspection. Bacterial growth is what is to be 
feared in the milk^ and this can be prevented by keeping 
the milk at low temperatures. If the infant's food or milk 
cannot be kept below 50° F., it should be pasteurized or 
sterilized as soon as possible^ as, while the bacteria are 
killed by heat, the toxins they produce are not destroyed. 

Heating produces many changes in milk, some of 
which are not thoroughly understood. Boiled milk does 
not curdle with rennet as easily as raw milk, the cream is 
about one-third denser than the cream of raw milk, and 
the albumin is rendered insoluble. 

The following table by C. H. Stewart shows the per- 
centage of soluble albumin in milk at various tempera- 
tures : — 





Soluble Albumin 


Soluble Albumin 


Time of Heating. 


in Fresh Mill^. 


in Heated JIill\ 




Per Cent. 


Per Cent. 


10 minutes at 60° C. (110° F. ) 


0.423 


0.418 


30 minutes at 60° C. ( 140° F. ) 


0.435 


0.427 


10 minutes at Qb° C. ( 149° F. ) 


0.395 


0.362 


30 minutes at 65° C. (149° F. ) 


0.395 


0.333 


10 minutes at 70° C. ( 158° F. ) 


0.422 


0.269 


30 minutes at 70° C. ( 158° F. ) 


0.421 


0.253 


10 minutes at 75° C. ( 167° F. ) 


0.380 


' 0.070 


30 minutes at 75° C. (167° F. ) 


0.380 


0.050 


10 minutes at 80° C. (176° F. ) 


0.375 


none 


30 minutes at 80° C. ( 176° F. ) 


0.375 


none 



Changes in Milk Caused by Sterilization. 

In some late experiments made by Dr. E. M. Hies- 
land and published by Dr. B. C. Hirst""^ Dr. Hiesland 
found that by sterilization: 1. The albumin is coagulated. 
2. Casein less readily precipitated by rennet than in nor- 
mal milk. Acid corrects this condition. 3. Fat is freed 
to a slight extent; fat not freed has a lessened tendency 



^* Medical News, January 31, 1891. 



156 INFANT-FEEDING. 

to coalesce. 4. Sugar undergoes some change^ as shown 
by its lessened dextrorotatory power. The considerations 
suggested by a knowledge of the foregoing facts are: — 

1. The coagulation of milk-albumin by sterilization 
may render the milk more difficult of digestion. 2. 
Sterilization interferes with the coagulability of milk by 
rennet^ and presumably, therefore/ with its digestibility 
by the gastric juice. 3. Free fat, as found in sterilized 
milk, is probably not readily assimilated in infant-food. 
The fat not free, being inclosed in a less easily destructible 
envelope, is probably slow of digestion.^^ 

On the question of sterilized milk the weight of evi- 
dence seems to show that the process, while preventing 
undue fermxCntation, so changes certain of the natural fer- 
ments and some of the fats that the milk is less easily di- 
gested and less nutritious. ^^ 

At the New York Medical Association's meeting, 
March 16, 1891, Brush read a paper on "Sterilized Milk,^^ 
in which he objected to the sterilization of milk for in- 
fants' food because the process devitalized it. Among the 
other ways in which the value of the milk was lessened 
by sterilization, he said, was that the soluble albumin was 
made insoluble. He believed that a child raised on steril- 
ized milk would be less robust, and have a constitution 
that would more readily succumb to deleterious influences 
than one fed on natural milk. He contended that every 
human being required some living food, and that the 
cause of every scurvy was deprivation of such living food. 
The sterilization of milk for adults was of but little con- 



'' Medical Record, February 28, 1891. 

^"^ North American Practitioner, June, 1892, from the "Year- 
book of Treatment" (Lea Brothers & Company). 



CHANGES IN MILK CAUSED BY STEEILIZATION. 157 

sequence, as they had other kinds of food; but it be- 
comes a matter of the highest importance to an infant 
whose only food was milk.^^ 



Boston JNIedical and Surgical Journal, April 9, 1891. 



CHAPTER XXII. 



Steeilized Milk. 



E. G. Freeman, M.D., in a paper read before the 
Academy of Medicine, New York, May 11, 1893, says, of 
sterilization, that, when milk is sterilized at 212° F. (100° 
C), absolute sterilization is not obtained, bnt the milk is 
rendered less digestible than it is in the raw state, and 
physicians who have used sterilized milk as a regular food 
find that often infants so fed do not thrive. This clinical 
experience chemists state is occasioned by the many modi- 
fications produced in milk by this temperature of 212° F., 
the starch-liquefying ferment being destroyed, the casein 
being rendered less coagulable by rennet and therefore 
being acted upon slowly and imperfectly by pepsin and 
pancreatin, and the milk-sugar being destroyed; these 
chemical changes begin to be marked when a temperature 
of 176° F. (80° C.) is reached, and become more marked 
as the temperature becomes higher. 

In the Medical Age, September 25, 1893, it is stated 
that Dr. Fayel, of Caen, France, says boiled milk is more 
or less indigestible, and is in no respects safer than un- 
boiled milk; the temperature at which milk boils is in- 
sufficient to destroy microbes, and the milk is therefore 
not sterilized, while its density is increased by the boiling 
above that which is suitable for infant-digestion. 

In the Therapeutic Gazette, October 16, 1893, is a 
translation from a communication to the Societe de Mede- 
cine de Lyon, by Crolas. Crolas concludes that boiling 
milk relieves the milk of small quantities of butter, but 
has no action whatever upon the casein or lactose; that 

(158) 



STERILIZED MILK. " 159 

the boiling increases the quantity of soluble phosphates. 
He therefore believes that boiled milk as an article of food 
is equivalent, if not superior, to unboiled milk. 

At the meeting of the ]N"ew York Academy of Medi- 
cine, Section in Pediatrics, May 12, 1892, Dr. A. Jacobi, 
in the discussion upon infant-foods, made the following 
points: — 

It was a great error to suppose that sterilized milk 
was anything like human milk; it required just as much 
modification as though it were not sterilized. 

Alkalinity in cows^ milk was always suspicious, for it 
was evidence that it had been "doctored." The most 
dangerous alkali was bicarbonate of soda, for in milk thus 
treated the ptomaine-producing germs develop best. 

While pepsin was sometimes useful, he objected to 
its indiscriminate use; without an acid it was inert. 

Sugar was required in an artificial food, but he did 
not believe that milk-sugar was best. There was a close 
relationship between milk-sugar and lactic acid. The 
change from one to the other was very rapid. Some lactic 
acid was necessary for proper digestion, but an over- 
quantity produced hyperacidity and indigestion.^^ 

Excerpt from an address at the Eleventh Inter- 
national Congress, Eome, Italy, April 4, 1894, by A. 
Jacobi, M.D.: — _ 

"I shall only dwell upon two articles which have 
taken an improper hold on the imagination of medical 
men and have almost been raised into subjects of super- 
stitious veneration. The use of milk-sugar in the place of 
cane-sugar in children's food, to any extent beyond what 
there is in cows' milk or its exclusive employment is a 



Virginia Medical Monthly, June, 1892. 



160 INFANT-FEEDING. 

source of acid gastric catarrh, which afterward requires 
medicinal correction; it is transformed into lactic acid 
beyond need and proves' a detriment, to the full conviction 
of all those who will give the subject proper attention. 
Thoughtful experience is as valuable an objective addition 
to our knowledge as a mere chemical or theological theory. 

"Next in order is sterilized milk, on which hundreds 
of thousands of babies are now being fed to the exclusion 
of everything else. Nobody would teach nowadays the 
feeding on unchanged or unmixed cows' milk to babies as 
a proper course to take, — as a substitute for mothers' 
milk. But sterilized milk has been looked up to as an ob- 
ject of faith and treated as a pope among foods, infallible. 
To feed babies exclusively on sterilized milk has become 
the rage since it was recommended by gentlemen of the 
highest possible standing in science, but, as far as I know, 
little conversant with the art of treating well and sick in- 
fants. I speak so bluntly because I love babies, one and 
all. 

"Sterilized milk — pasteurized is inferior to it — is su- 
perior to unchanged cows' milk, still not human. Of 7 
cases observed this winter of infantile scurvy, — a nutri- 
tive disorder as far as we can make out, — there were 3 
that had been fed, 2 exclusively, 1 for several months, on 
sterilized cows' milk."^^ 

The Chemical and Physiological Changes in 

Milk Caused by Boiling.^^ 
Milk consists of a multitude of cells suspended in 
serum. The cells are fat-cells, which form the cream; the 



^^ Medical Record, May 19, 1894. 

*« J. L. Kerr, M.D., CM., F.R.S.E., in the British Medical Jour- 
nal, December, 1895. 



CHANGES IN MILK CAUSED BY BOILING. 161 

remaining cells are nucleated, and of the nature of white 
blood-corpuscles. The serum consists of water, in which 
is dissolved milk-sugar and serum-albumin, with various 
salts, and, chief of all, casein. The cells, with the excep- 
tion of the fat-corpuscles, are all living cells, and they re- 
tain their vitality for a considerable time after the milk 
is drawn from the mammary gland. 

There is reason for supposing that, when fresh milk 
is ingested, the living cells are at once absorbed without 
any process of digestion, and enter the blood-stream and 
are utilized in building up the tissues. The casein of the 
milk is digested in the usual way of other albuminoids by 
the gastric juice, and absorbed as peptone. There is also 
absorption of serum-albumin by osmosis. The chemical 
result of boiling milk is to hill all the living cells and to co- 
agulate all the albuminoid constituents. Milk after boil- 
ing is thicker than it was before. 

The physiological results are that all the constituents 
of the milk must be digested before it can be absorbed 
into the system; therefore there is distinct loss of utility 
in the milk, because the living cells of fresh milk do not 
enter into the circulation direct as living protoplasm, and 
build up the tissues direct, as they would do in fresh, un- 
boiled milk. In practice it will have been noticed by most 
medical practitioners that there is a very distinctly appre- 
ciable lowered vitality in infants which are fed on boiled 
milk. The ^^rocess of absorption is more delayed and the 
qucuiUty of milk required is distinctly larger for the same 
amount of growth and nourishment of the child than is 
the case when fresh milk is used. 



162 infant-feeding. 

Pasteurization of Milk. 

Heating milk to 75° C, as is done by many of the 
methods, does not sterilize, for the spores of the baeillns 
subtilis can withstand this temperature for several days. 
The spores will resist the temperature of 100° C. (212° F.) 
for six hours. Upon heating to 110° to 120° C. (230° to 
2-48° F.) the milk will be thoroughly sterilized, but such 
heating causes a browning of the milk, and the cream- 
cells are apt to be broken and the fat or butter will rise 
to the surface.''^ 

Pasteurization with a temperature between 70° and 
80° C. (158° to 176° F.) destroys tubercle bacilli and, ac- 
cording to Van Geuns, destroys also the typhoid bacillus, 
the cholera bacillus, and the pneumococcus of Friedlander, 
and also most of the ordinary milk germs, and does not 
injure the milk.*^ 

Sterilized Milk. 

Sterilized milk is, according to Marr,*^ as badly borne 
in children's dyspepsias as ordinary milk, for, even when 
sterilized by Soxhlet's apparatus, milk is still prone to de- 
composition, and hence favors the decomposition-proc- 
esses present in the diseased digestive tract. 

Dr. B. Bendix** studied the question as to the rela- 
tive value of sterilized and unsterilized milk. In a paper 
recently published he arrives at the following conclusions: 
Sterilized and unsterilized milk have an equal value in 
nourishing both sick and well children. The change in 



*^ Molt-Zeitung. 

^ Medical Record, July 2, 1892. 

*^ London Medical Recorder. 

^ Jahrbuch fiir Kinderheilkunde, 38. 



STERILIZATION OF MILK. 163 

taste and odor caused by the sterilization is no cause for 
the refusal of the same by infants^ as sterilization destroys 
both the pathogenic bacteria^ as well as the bacteria caus- 
ing fermentation and decomposition; so he believes that 
it is the duty of every physician to insist on substituting 
sterilized milk when breast-milk cannot be had, and^ as 
he believes that sterilization does not cause difficulty of 
digestion, he prefers the latter to pasteurized milk. 

Koplik"^^ studied the comparative value of sterilized, 
pasteurized^ and other milks, and found that some weeks 
pasteurized milk and other weeks a sterilized milk would 
show advantages which, however, would hardly decide 
for or against either method of preparing the food. The 
author believes that it is rather the food that should be 
looked after than the method of feeding it. 

Steetlizatio]s^ of Milk at 218° F. for Thirty 

MlJsTUTES. 
METHOD OF STERILIZING (SOXHLET METHOD). 

Bottle-cUansing. — Always cleanse the bottles thor- 
oughly before using if they are new bottles. It is a good 
plan to give them one good washing by adding a pinch of 
common washing-soda to each bottle, boiling for at least 
five minutes in this soda-water, and then boiling for at 
least a quarter of an hour in ordinary water. The bottles 
are then turned upside down to allow the water to drain off. 
I then insert a large stopper consisting of non-absorbent 
cotton (ordinary cotton, from a dry-goods store, which is 
non-absorbent, is far better than the white absorbent cot- 
ton). The neck of the bottle is stoppered at least three- 
quarters of an inch. 



New York Medical Journal, April 13, 1895. 



164 



INFANT-FEEDING. 



/)()/tl<'-h((/iin(/. — If we wisli to dry them hurriedly, 
then several of these hottles eau he placed in a large fry- 




Fig. 20. 

ing-pan with a piece of pasteboard hetween each bottle, 
and baked thoroughly dry for about a half-hour. This not 
only dries them, but baking them really sterilizes them. 



STEEILIZATIOX OF :\IILK. 165 

Place the bottles — previously filled with milk or the 
feeding mixture — in the rack^ and set the rack in the 
sterilizing chamber^ and cover up tight with the lid and 
hood. 

Fill the reservoir (pan) two-thirds full of water and 
place the apparatus over a moderate fire for one hour. If 
the milk is just from the cow^ -iO or 50 minutes are suffi- 
cient (20 ]ninutes for heating and 20 or 30 minutes for 
sterilizing). 

The sterilizer may be used on a gas-stove (turned 
low), kerosene-stove, or upon an ordinary cooking-stove: 
if over the last, the griddle should not be removed. You 
can tell by a bubbling sound that the sterilizer is working 



Fig. 21. 

all right. If the water is not bubbling with regularity in- 
side, you need more heat. It must not be put on the fire 
Avithout water in the reservoir, and the water should never 
be allowed to get lower than one inch from the bottom. 

With proper attention as to the quantity of water in 
the reservoir no further care need be given to the appara- 
tus, or to the contents of the chamber, for the prescribed 
time. 

It is not necessary to place the bottles on ice after 
removing them from the sterilizer, but all bottles should 
be put into a refrigerator until taken out for feeding, leav- 
ing in the cotton plugs until it is feeding-time. The di- 
rections sent out with some sterilizers, that milk will keep 
for days, implies that infant's milk may be prepared for 



166 INFANT-FEEDING. 

several days at once. To this I decidedly object. A great 
many authors have pointed out cases of Barlow's disease 
due to milk which had been sterilized and not used for a 
very long time. Before feedings the bottle is to be prop- 
erly warmed by putting it into a small measure or bottle- 
holder and heating it with alcohol or gas to about the 
body-temperature of 98° or 100°. Immediately before 
using shake the bottle^ so as to mix the cream and the 
milk, which invariably separate in a refrigerator; remove 
the cotton and draw on the nipple. 



CHAPTER XXIII. 

Pasteurized Milk. 

Booker states that certain germs may not be harm-, 
fill to the baby, if introduced into its body, but are in- 
jurious to the milk. For example, bacillus lactis aerog- 
enes. These germs are destroyed at a low temperature. 
Booker does not believe that the disturbances claimed to 
be caused by the sterilization of milk are warranted; nor 
does he believe that sterilized milk per se causes scurvy. 

Freeman states that high-temperature sterilization 
causes chemical changes in milk: — 

Change in taste at 70° C. (158° F.). 

Chemists note changes at about 80° C. (176° F.). 

Freeman believes bottle-food to be a predisposing 
cause of scurvy. He states that a low temperature, pro- 
longed, acts as well in destroying pathogenic germs as the 
action of a high temperature for a short time. He advises 
68° C, equivalent to 155° F., for 30 minutes, followed by 
rapid cooling. Such a temperature will destroy the germs 
of diphtheria, typhoid, and tuberculosis, and other germs, 
proved by the inoculation of a plate at laboratory tempera- 
ture, showing no growth after twenty-four hours. Free- 
man does not believe that our present dairy can furnish 
a raw milk which is absolutely safe as an infant-food, be- 
cause, he says, milk must be obtained by pressure on the 
teats of a cow, and these teats hang beneath an udder, 
which is covered with hair, and from the belly of the cow, 
which is also covered with this same hair covering. More- 
over, this portion of a cow is particularly liable to be 

(167) 



168 INFANT-FEEDING. 

soiled with dirt, as it conies in contact with the ground 
when the cow lies down. Its hairy covering, moreover, 
holds the dirt^ wdiich is gradually shaken out hy friction. 
If the cow has loose stools, these run down the inner sur- 
face of the thigh and the posterior portion of the udder. 
The contamination dries on the u.dder, in the air, and 
during milking is apt to fall as dust in the pail. More- 
over, the milk-ducts of the cow may contain many bac- 
teria, although usually contamination from this source is 
not very great. Freeman further says: "The milkman's 
hands are almost never clean. His hands are employed 
in handling manure, and in attending duties involving 
contamination. Occasionally they are used during the day 
in waiting on some one sick with a contagious disease, 
and, when such is the case, the consumers of the milk are 
apt to suff er.^^ 

The author read a paper by Prof. Adolf Baginsky, 
on "The Milk-supply in the Kaiser and Kaiserin Fried- 
rich Childreif s Hospital in Berlin," before the Section on 
Diseases of Children, at Atlantic City, in June, 1900, 
wherein Baginsky says that, before milking a cow, the 
stable is cleaned with a damp cloth. All the dirt is re- 
moved, and finally the stable is cleaned with water. Prior 
to milking, the Swiss milkmen are compelled to thor- 
oughly cleanse themselves, giving especial attention to 
their hands. These are cleaned with soap and brush. 
Great stress is laid on washing the udder of each animal 
with warm soap-water, and dried with clean cloths. In 
this manner the infection wdth hair and stable-dirt is pre- 
vented. The milk is not allowed to remain in the stable 
until all the co^vs are milked, but as soon as a pail is filled 
it is at once 7'emoved to the dairy, thus preventing the 
danger of contamination with bacteria, which are found 



PASTEURIZED MILK. 



169 



ill the air of the stable, and which are very hard to destroy 
by sterilization. These are the bacteria of the hay- and 
potato- bacillus groups. Another vital point is that warm 
milk easily absorbs the A^arious stable-odors, and fre- 
quently has a distinct "stable-flayor." 

If what Freeman claims might happen, — namely: the 
introduction of filth, manure, and f^cal matter into the 
milk during the milking process, — then it seems to me 




Fig-. 22. — Author's Choice of Feedino-bottle. 



that such milk should be discarded entirely, for it is 
hardly conceivable that sterilizing or pasteurizing can 
modify milk contaminated in such a manner. Following 
the precepts of Professor Baginsky at Berlin, the main 
point is to insist on the strictest ^^stable-hygiene/'' and 
thus try to sterilize everything pertaining to the cow, the 
stable, and the utensils, and in this manner seek to obtain, 
by the strictest attention to cleanliness, "a strictly-clean 
milk." 



170 



INFANT-FEEDING. 



Directions for Pasteurizing MilJc. — Pasteurization is 
really sterilization at a temperature of 167° F. Experi- 
ence lias shown that the bacteria usually found in milk 
and those which would be harmful for an infant can be 
destroyed by subjecting milk to a temperature of 167° to 
170° F. for 15 to 20 minutes. For this purpose Freeman 
lias constructed his pasteurizing apparatus (see Figs. 23 
and 24), which, however, is rather expensive, although ex- 
tremely useful. The author has used it and has been well 
pleased with the result. 



I 




Fig. 23. 



Freeman^s pasteurizer consists of a metal pail into 
which a rack is placed holding the bottles exactly as is 
found in the ordinary sterilizing apparatus. This metal 
pail is partly filled with water up to its first groove, and 
the water heated to the boiling-point. Until the water is 
brought to the boiling-point, the bottles are not intro- 
duced within the kettle. The bottles, previously filled 
with the required mixture of the infantas food, are held 
in readiness, and, when the water boils in the metal pail, 
the lid is removed, the rack with the bottles placed on the 
inside of the metal pail, and the heat turned off, or the 



PASTEUEIZED MILK. 



171 



pail is removed from the fire. The pracess consists in 
allowing the water to cool, whereby the bottles and the 
milk get warm for a period of 30 to 15 minutes. After 
45 minutes, the lid is again removed, the metal pail con- 
taining the bottles of milk are taken to a water-trough or 
sink, and the cold-water fancet, over which a piece of rub- 
ber pipe is fitted, is turned on, and the water permitted to 
flow on the inside of the pasteurizer. In this way there 
is a gradual displacement of the warm water by this cold 
water, until the water is all cold. 




After the bottles are sufficiently cooled, they should 
be removed to the refrigerator. The rapid cooling of the 
bottles is as important as the pasteurization by the heat. 
Pasteurized milk should be kept no longer than twenty- 
four hours. We can pasteurize in other ways with any 
ordinary sterilizing apparatus. Thus, the Arnold steam- 
sterilizer (see Fig. 20), leaving the hood ofi, can be utilized 
for this purpose. To be sure that we are attaining the cor- 
rect temperature, we can insert a special thermometer, 



172 INFANT-FEEDING. 

wliicli is made 'I'or sterilizing bottles. It can be procured 
from any chemist or from tlie Arnold Sterilizer Company. 

To pasteurize with any ordinary sterilizer^ set a 
thermometer into one bottle and put the sterilizer on a 
brisk fire until the thermometer reaches 170° F. Then 
remove to the back of the stove^ take out the ther- 
mometer, stopper the bottle that contained the same, and 
cover with a hood or the lid of the tin pail for fifteen 
minutes. Then fill the inside of the pail with hot water 
around the bottles as near to the top as possible, remove 
to the sink, and allow a stream of cold water from the 
faucet to displace the warm water. • A point worth noting 
is that the cold water must not be allowed to splash on 
the hot bottles, otherwise it will crack them. It usually 
takes about ten minutes to gradually displace the hot 
water in the tin pail or kettle used as a sterilizing cham- 
ber, after which the bottles of milk are to be placed in 
a refrigerator and left there until ready for use. It is 
understood that each bottle is to be warmed to about a 
body-temperature of 98° to 100° immediately before feed- 
ing. 

In a letter recently received by the author Prof. 
Victor Vaughan says he does not believe that milk is ren- 
dered more digestible by sterilization or pasteurization. 
He thinks that if milk could be obtained under complete 
aseptic precautions, sterilization, as a preparation for in- 
fant-feeding, would not be necessary. However, either 
sterilization or pasteurization is imperative when market 
milk is used, because this is seldom or never obtained 
under aseptic precautions. Some people have an idea that 
it matters not how filthy a milk is, or how many germs 
it may contain, if it be pasteurized or sterilized it becomes 
a fit food for children. This is not true, because, in the 



PASTEURIZED MILK. 173 

first place, even prolonged boiling doe>s not kill the spores 
of all bacteria; and^ in the second place, the chemical 
poisons produced by certain germs are not altered by the 
temperature of boiling milk. After milk has been either 
sterilized or pasteurized it should be kept at a low tem- 
perature before being fed to the child. This should be 
regarded as a necessary procedure in the preparation of 
infant-food. The fact that milk in which the colon germ 
has already grown abundantly cannot^ by any process of 
sterilization or pasteurization, be rendered fit food for 
children should be emphasized. The toxin of the colon 
luiciJJus mail ^^'' ^i<''ited to 180° C. (356° F.) for half an hour 
witliout liariiKj its poisonous properties diniinislied. If 
clean milk be obtained and pasteurized at from 155° to 
158° C. and then kept at a low temperature until fed to 
the child, it furnishes the best food which it is possible 
for us to obtain under ordinary circimistances. 



CHAPTEK XXIV. 



Tyndallization, 



When milk is subjected to a temperature of 212° F. 
for from 15 to 20 minutes on three successive days, such 
process is called tyndallization. When such a procedure 
is instituted, we certainly obtain the "absolutest sterility 
possible" of the milk. 

Such milk, however, is not adapted for infant-feed- 
ing, owing to the changes brought about by this continued 
application of heat in rendering the albuminoids and salts 
contained in the milk more difficult to digest. 

Milk subjected to this tyndallization has all the dis- 
advantages of a prolonged sterilized milk or milk-mixture. 
My experience is decidedly in favor of avoiding such con- 
tinued heating of milk, and I am sure that many cases of 
scurvy can be traced to the lack of fresh albumin and. 
casein assimilated. 

It is certainly peculiar that in spite of the experience 
of many noted men, the author has recently seen a decided 
improvement in a child suffering with scurvy when the 
food was changed from sterilized milk^to a raw-milk mixt- 
ure, the milk-mixture being merely warmed to a feeding 
temperature. 

Barlow's disease can frequently be traced to improper 
feeding, especially when mothers are permitted to use 
their experience in making up their own feeding-mixtures. 
Children are more frequently starved than will be ordi- 
narily admitted, and, were it possible to examine the food 
given to the average infant and compare it with a stand- 
ard breast-milk suited for the age of the infant, we would 

(174) 



TTNDALLIZATION. 175 

soon learn that our crude methods resulted in positive 
harm^ the result of which years of proper medication and 
feeding will hardly be able to remedy. 

The vital point to remember is to get the child prop- 
erly started^ and we must not be discouraged if our first 
feeding-mixture is not properly digested or assimilated. 
In such instances we will soon learn which elements of our 
food require more proper modification and elimination, 
especially so if the stools are studied. 

Tyndallization will permit milk to be kept for 
months, and is just such milk which, fed to weakened chil- 
dren, will ultimately cause Barlow^s disease or its allied 
conditions. AVhile in Berlin several years ago I was given 
milk which had been sterilized six months previously. 
While it is true the taste did not betray the length of time 
that the milk had been kept, it can be easily seen that cer- 
tain chemical changes will develop, altering the character 
of the food. 

It is my belief, founded on extensive experience, that 
sterilized milk, continually fed, to the exclusion of raw 
milk and raw beef-juice, will ultimately result in rachitis 
or scurvv. 



CHAPTEK XXV. 



Nipples and Bottles. 



Attention to this j^ortioii of the feeding apijaratiis 
is very important, as the cause of sore mouth and tongue 




Fiff. 25. 



and gums can frequently be traced to a filthy nipple 
Such infections can be easily aA^oided in the following 




Fig. 2G. 

manner: The nipples are to be boiled for about ten or 
fifteen minutes in a so-called nipple-sterilizer (see illustra- 
1 ration, Fig. 29), placed in a tin pail of plain water to 
(176) ' 



XIPPLES AND BOTTLES. 



177 



which a pinch of salt has been added. After boilng in 
this manner the nipple shonld he put into a tumbler of 



/^iii?^ 




Q I illustr;ition q 



ACTUAL SIZE 




Fig. 27. 




Fio-. 28. 



plain, sterilized (boiled) water and allowed to soak until 
it is time to use it. It is advisable to boil every nipple im- 
mediatelv after removino- it from the feeding-bottle bv 



178 INFANT-FEEDING. 

turning it inside out, placing it in the sterilizer, and 
steaming it for 15 or 20 minutes. In this manner all 
pathogenic bacteria are destroyed, and all particles of milk 
which adhere to the rubber are removed. Such nipples 
will not be the cause of stomatitis or other infectious 
mouth disorders. 

The choice of a nipple is another important matter. 
My preference has always been for a black-rubber nipple, 
and it is a very wise point to use a nipple no longer than 
one week; in other words, old, worn nipples are useless 
for the proper management of infant-feeding. Black rub- 
ber is softer than white rubber; most white rubber is sup- 
posed to contain lead; hence a decided reason for not using 
it. 

Nipples Recommended. — One of the best nipples made 
is the so-called anticolic nipple. This nipple has a ball- 
shaped top, which enables a baby to take a firm hold; it 
has three small holes, which give an easy flow of milk, 
and regulate a slow meal. Nipples having very large open- 
ings, which will permit a baby to finish a 6- or 8-ounce 
bottle of food in five or six minutes, are useless,^ and this 
gulping of food is really the cause, or one of the causes, of 
infantile colic. Another nipple I have used, but it is much 
harder to clean, and, unless all precautions for steriliza- 
tion are carefully noted, this nipple should not be used; 
yet, in the hands of the intelligent or where we have a 
trained nurse, it can be safely recommended. It is called 
the "Mizpah." The nipple has also a very small puncture; 
so that the baby gets the food slowly. 

The "Swan Bill" nipple or the long French nipple I 
do not like, nor have I noted results as good as with the 
above-mentioned kinds. 

Ventilated Nipple. — A nipple very highly spoken of 



NIPPLES AND BOTTLES. 



179 



is the ventilated nipple made by Ware, of Philadelphia^ 
which has a small opening or valve on the side, and, as the 
milk is drawn in from the bottle, it permits air to enter, 
thns preventing a vacuum from being formed. It is also 
supposed to be non-collapsible, and is highly recommended 




Fig. 29. — Nipple- sterilizer. 

by those that have used it. The only objection — already 
offered — is that all nipples must not only be practical for 
use, but must be capable of thorough sterilization. 

Odor of Nipples. — Children will object most decidedly 
to nipples having any odor or taste; hence it is a good 
plan to boil every new nipple before using it. 




Bottle-brush. 



The nipple-sterilizer (see Fig. 29) is a very convenient 
little arrangement made by Ware, of Philadelphia, and 
resembles a coffee-strainer with a lid. It is neat, cheap, 
and serves its purpose admirably for the sterilization of 
the nipple. 



180 



INFAXT-FEEDING. 



has a long handle and bristles for 



The butflc-brusli 
cleansing the bottles. This brush should be used before 
the bottles are put in the soda .solution, and serves for 
cleansing the inside of the feeding-bottles. It is self- 




Fig. 31.— Bottle-brush. 

understood that the hriish can itself harbor bacteria and 
particles of milk removed while cleansing^ It is therefore 
important that the brush should be thoroughly boiled in 
a washino;-soda solution after each use. 




Fig. 32. 



Feeding-bottles. 



The long 8-ounce feeding-bottle, or 



o-called feeding- 
tube, wbich is illustrated, is certainly a unique bottle for 
feeding; as it has no corners and no useless rims, besides 
the inside, it can be very easily cleaned. 



being smooth on 



Is^IPPLES AND BOTTLES. 



181 



All bottles liaying angles and depressions should be 
avoided. The boat-shaped bottle is also yery good, bnt 
much harder to clean. 




Fig. 33. 



My preference has always been for two kinds of 
bottles: 1. Those holding four ounces and graduated on 
one side in both ounces and tablespoons. This sayes quite 




Fig. 34. — Baby-comforter. Not Advised by the Author. 

some time and trouble. 2. Bottles holding eight ounces 

and divided off into 16 tablespoonfuls or 8 equal ounces. 

Exactness of Ounces. — It may not be out of place to 



182 INFANT-FEEDING. 

ask each physician to insist on having the graduated 
ounces on an infant's feeding-bottle measured with an 
accurate graduate, obtainable at every drug-store. In 
many instances the author noted feeding-bottles wherein 
the ounces were very unequal^ and in one particular bottle 
the eight graduated ounces on the bottle held twelve 
ounces. 

Long JRuhher Tubes. ■ — Most prominent pediatrists 
agree that the long rubber tubes are a convenient place 
for harboring micro-organisms, and they have been uni- 
versally condemned. 



CHAPTER XXVI. 

Dextkinized Geuels. 

We have preYiousl};- referred to the method of makiug 
flour ball, in the section on "Additional Foods during the 
Xursing Period/' In some instances, especially where di- 
gestion is subnormal, beneficial results will follow the 
dextrinizing of infant-foods. Thus, the starch of the gruel 
is held in solution, and the remaining cellulose and pro- 
teids of the cereal are left to act on the curds. 

Method of Dextrimzing. — Prepare the wheat-, barley-, 
oatmeal-, or rice- flour by adding a tablespoonful of the 
same to a pint of water, adding a pinch of salt, and boiling 
the same for from fifteen minutes to one hour. This will 
make a gelatinous solution, and hence the name of barley- 
jelly, rice- jelly, oatmeal-jelly, or wheat- jelly. We allow 
this jelly to cool, and when cool enough to be tasted we 
can add a diastase, such as cereo; or taka-diastase, made 
by Parke, Davis & Co.; or the Forbes diastase. When a 
small quantity of this diastase is added to the jellies above 
mentioned, they lose their thickness, and become very 
thin. They can easily be strained through cheese-cloth, 
and some water added to make up for the loss by evapora- 
tion during the boiling. This jelly, or gruel as it is some- 
times called, made from either barley-, rice-, wheat-, or 
oat- jelly, is to be used with the milk after the diastase is 
added. In certain diseases, where milk is not well borne, 
such as dyspepsia (dyspeptic vomiting) or in summer com- 
plaint, where the giving of milk is prohibited, feeding the 
(lextrinized gruels for several days will be found, not only 
very useful, but very healthful. In making this dex- 

(183) 



184 INFANT-FEEDING. 

trinized gruel, small particles will be seen floating, which 
settle out upon standing. These particles consist of the 
cell-walls and the proteids of the cereal, and cut the curds 
of the milk into fine pieces, when the curds begin to shrink 
under the combined action of rennet and acid. In using 
this diastase we aim at breaking up„ the tough curd in 
cows' milk by purely-mechanical means. 

Henry D. Chapin {Journal of the American Medical 
Association, July 14, 1900) says: "The next important 
step is to get the cows' milk as nearly as possible in the 
same physical condition as mothers' milk. The diluent 1 
prefer to use is a wheat-, barley-, or oatmeal- gruel, the 
starch of which has been digested or dextrinized by the 
action of diastase. A heaj)ing tablespoonful of flour, made 
from a cereal, is boiled with about a pint and a half of 
water for fifteen minutes. It is then removed from the 
stove and set in. cold water for about three minutes to cool 
it. When it is sufficiently cool to taste, a teaspoonful of 
a preparation of diastase is added, which renders the gruel 
thin and watery. This makes about a pint of gruel, con- 
taining the starches in soluble form, while the cellulose, 
or skeleton of the cereal, acts as a most effective attenu- 
ant of the curd. These digested gruels render the milk- 
curd porous, and also provoke the secretion of the digest- 
ive juices. As diluents, they are a great improvement on 
water. Most of the thick malt-extracts are sufficiently 
active in diastase to produce the desired effect." The 
writer, how^ever, prefers the employment of diastase itself, 
without any of the other malt ingredients, as being both 
speedy and efficient. It can either be produced cheaply at 
home or purchased at the nearest drug-store. A simple 
decoction of diastase may be made as follows: A table- 
spoonful of malted barley-grains is put in a cup, and 



DEXTEINIZED GRUELS. 185 

enough cold water added to cover it, usually two table- 
spoonfuls, as the malt quickly absorbs some of the water. 
This is prepared in the evening and placed in the re- 
frigerator over night. In the morning the water, looking 
like thin tea, is removed by a spoon or strained off, and 
is ready for use. About a tablespoonful of this solution 
can be thus secured, and is very active in diastase. It is 
sufficient to dextrinize a pint of gruel in ten to fifteen 
minutes. Preparations of diastase are made by a number 
of chemists: Forbes; Parke, Davis & Co.; Horlick, and 
others. There is now obtainable an active glycerite of 
diastase known as cereo, which is specially made for the 
purpose of dextrinizing gruels. 

The author has seen very good results follow the ad- 
ministration of any and all of the malt-extracts now in 
our market during the past summer, in those critical 
cases of summer complaint in which subnormal digestion 
existed. 

Frequently the administration of a teaspoonful of 
malt-extract to an infant immediately before feeding was 
not only relished by the infant on account of the pleasant 
taste of the malt, but certainly aided in the assimilation 
of the food. Earely was more than 3 teaspoonfuls of malt 
ordered during twenty-four hours. Such preparations like 
maltine and also maltzyme gave very good results. The 
malt-extract of Parke, Davis & Co. has a very pleasant 
flavor and seems well borne. 

Frequently, when expense proved an important item, 
sufficient dextrinization of foods could be procured with 
these malt preparations above cited. 

It is claimed that, while most malt preparations de- 
teriorate on standing or if exposed too long, cereo will 
keep indefinitely. 



PAET II. 

CHAPTEE XXYII. 

Incubatok-feeding. 

When we consider that the usual viability of a child 
is placed at twenty-eight weeks of intra-nterine gestation, 
then we can see how vastly different the method of feed- 
ing must be from that of a child born at term, or a so- 
called "full-born child." 

Method of Feeding. — The size of the child precludes 
the taking of an ordinary-sized nipple, and hence various 
measures have been tried, the most successful of which 
have been, according to the author's experience, in feed- 
ing with a small medicine-dropper at intervals of two 
hours, the quantity varying with the age of the infant. 
It is a good plan, considering the capacity of the infant 
at*4;erm to be 1 ounce, to recognize the deficiency in the 
development of not only the size and capacity of the 
stomach, but also its lack of digestive function. Hence 
my plan has been to commence feeding by giving two 
teaspoonfuls of milk diluted with two teaspoonfuls of sugar- 
water; no lime-water and no salt added. 

A prematurely-born baby is necessarily doomed with- 
out proper food, and there are so many other factors to 
be considered during its life in an incubator, such as its 
ventilation, its bodily warmth and cleanliness, that too 
much stress cannot be laid on the value of its food. With- 
out breast-milk, therefore, I feel justified in sa3dng: I 
have yet to see the premature infant that will survive, 
and hence I advise procuring breast-milk, containing no 

(186) 



INCUBATOR-FEEDING. 187 

colostrum-corpuscles, from a woman having a child any- 
where from two or three weeks to several months old, and 
diluting this breast-milk, as stated above, with a solution 
of cane- or milk- sugar. Yoorhees**^ says: "Eegarding the 
care of premature babies in incubators, we have relied 
mainly on diluted breast-milk, and have only employed 
cows^ milk in weak proportions when it was impossible to 
obtain the former. In our opinion, our results would have 
been much poorer without the help of mothers' milk." 

In rare instances, where infants are very weak, and 
seem to doze and will not swallow, a JSTo. 7- American Tie- 
mann & Co. rubber catheter, having a velvet eye, can be 
attached to a long rubber tube about one foot in length 
and ending in a little funnel, holding several ounces. (See 
illustration. Fig. 52.) With this funnel and catheter 
forced feeding — so-called gavage — can be performed. 
With the infant lying flat on its back, push the catheter 
slowly, but forcibly, through the mouth as far against the 
pharynx as possible, and continue to push the tube from 
the pharynx into the oesophagus and the stomach. In 
all, about from five to seven inches, rarely more, will be 
necessary to reach the stomach. The milk, properly di- 
luted with an equal quantity of milk-sugar solution, can 
then be allowed to flow in the stomach, and the catheter 
must then be very quickly withdrawn. Such feeding 
should be repeated once in four, five, or six hours, de- 
pending on the requirements of the case. Each infant is 
a law unto itself, and hence no cast-iron rule can be laid 
down, but each individual case should be studied sepa- 
rately and its requirements met as indicated. Thus I 
have found in a premature infant, born at seven months. 



Archives of Pediatrics, May, 1900. 



188 INFANT-FEEDING. 

that 6 draclims was enough for, one feeding, and this was 
well borne once in three hours. The food consisted of 
equal parts of breast-milk and milk-sugar water. This 
feeding was continued for one w^eek. when the child cried 
very much, and, on attempting to satisfy it, the infant 
swallowed 1 V2 ounces. We then alternated each feeding 
by giving a large meal of 1 ^ / .^ ounces followed by a small 
meal of 6 drachms, and fed in this manner every two 
hours until the child was three weeks old. We then gave 
1 ^/2 ounces of food every two hours. The child's stool 
was quite good; it soiled from two to three napkins every 
day, and, when it was very restless, we gave it from 2 to 
3 teasjDOonfuls of boiled water, which seemed to satisfy 
it. I would urge the necessity of giving plain, sterilized 
water freely to all infants living in an incubator. The in- 
creased temperature of its surroundings calls for it; so 
does also the necessity for eliminating through skin, 
bowels, and kidneys. 

Dangers of Feeding. — Very small quantities of food 
should be used in gavage — feedings of the mouth or when 
feeding through the nose. No more than 4 to 6 drachms 
should be used, and thus we can feel our way. It is a 
good point to remember that, the pharynx being very sen- 
sitive, the irritation of the tube in passing into the stom- 
ach may provoke regurgitation of some of this food, and 
frequently vomiting will be produced. In such instances, 
if the posterior nares or the pharynx is filled with food, the 
infant can easily suck some of this fluid during an inspira- 
tion into its trachea, and start up a pneumonia in the same 
manner as is done during the course of a child having a 
tube in the larynx in the treatment of laryngeal stenosis. 

Rectal feeding for premature infants is rarely called 
for, but it can and should be tried if the infant will not 



INCUBATOE-FEEDING. 189 

swallow and the forced feeding tlirongli tlie mouth or 
nose is unsuccessful. In such instances use very dilute 
milk^ thoroughly peptonized^, — the same proportions^ how- 
ever, as have been stated previously, namely: ^/^ milk 
and ^ / ^ water: the formula for rectal feeding should be: — 

IJ Breast-milk, V, ounce. 
Starch-water, ^/^ ounce. 

Add contents of 1 Fairchild peptonizing tube, and in- 
ject this quantity with an infant's rectal s3Tinge. (See illus- 
tration, Fig. 49.) The starch-water is made by taking 2 
teaspoonfuls of ordinary starch and mixing it with ^/^ 
teacupful of warm water (not boiling w^ater) and making 
a milky mixture of the same. This starch-water should be 
made fresh for each feeding. It is advisable to feed about 
once every six hours with the above solution. 

Cleanse the rectum thoroughly by washing with ^/^ 
pint of lukewarm, Castile-soap water to remove all fasces 
ten minutes before the nutrient fluid (peptonized milk) is 
.injected. 

PEE:\rATUEE IJs^FANTS (GEIFFITH). 

Premature Birtli. — A child may be born in the 
seventh or eighth month of pregnancy, or even earlier, 
long before it is quite ready to live outside of the mother's 
body, and when it weighs not more, perhaps, than two and 
a half or three pounds. AYe need not necessarily despair 
of the life of a baby, however unpromising it seems at 
first. Children born ai, six and a half months have grown 
up strong at last, although it is not often they survive if 
born before the seventh month. The great need of such 
a baby is heat, and the maternity hospitals employ an 
apparatus, called a couveuse, brooder, or incubator, espe- 
cially devised to supply it. (Fig. 35.) For family use, a 



190 INFANT-FEEDING. 

couveuse may be bought at the instrument-makers, or 
hired from some of them. This is, perhaps, better, as the 
apparatus is costly. But with an increased degree of at- 
tention it may be entirely done without fairly well. If 
a premature baby is bathed at all after birth, the tempera- 
ture of the water should be 102° F., and the greatest care 
should be taken, while drying, to see that the child is not 
chilled. It should be made very warm by swaddling it in 
raw cotton, head and all, leaving only the face exposed, 
wrapping it about with a blanket, and tying it around with 
a roller bandage. Hot bottles should be placed on each 
side of it as it lies thus wrapped up in the bed, and fresli 
ones be substituted frequently. A very convenient 
method is to place the child in a baby's bath-tub half-full 
of raw cotton in which numerous hot bottles have been 
concealed. The child's only clothing consists of a diaper 
and a shirt. The room should be kept warm, and espe- 
cially so when this human bundle is unwrapped for its 
bath. After bathing, it should be rubbed with sweet oil 
and be rolled up again in. fresh cotton. Often it is better 
to omit all bathing, and simply to rub with the oil. 

These premature infants lose considerably more in 
proportion to their birth-weight than babies at term. 
This is due to their immature digestive tract; also to the 
fact that they are almost invariably intensely jaundiced. 
They gain very slowly, and, if at the end of two or three 
weeks they have reached their birth-weight, they have 
done unusually well. 

In some of the babies the color is poor from the be- 
ginning, and at any time they are especially liable to at- 
tacks of cyanosis. For these conditions a little slapping 
to cause a good cry or the administration of oxygen will 
dissipate the blueness. Often a few drops of brandy in 



INCUBATOR-FEEDING. 191 

hot water every two or three hours will prevent further 
trouble. One must be very sure^ however^ that nothing- 
has been aspirated into the larynx. 

A great danger in the care of these babies is their 
susceptibility to infections. The incubator itself is a 
great germ-carrier^ and should be regularly disinfected. 
The weakness of the lungs and gastro-enteric tract makes 
the infants especially vulnerable. Unless the air is fil- 
tered, dirt is carried in continuously; consequently the 
streptococcus, staphylococcus, and pneumococcus are al- 
ways present, seeking an avenue of entrance. Through 
the skin in eczematous. spots or in areas of irritation, at 
the navel; through the eyes, nose, mouth, larynx, lungs, 
stomach, and rectum the bacteria can gain admission. To 
prevent infection the most careful cleansing is necessary, 
of both the incubator and the baby. Undoubtedly most 
of the deaths of our cases could be traced to this source. 

Finally, in the carrying out of the above essentials in 
the proper management of the premature infant, we re- 
quire the most patient and painstaking attention on the 
part of the nurse, and upon her conscientiousness depends 
the chance of its survival. 

Besults. — The statistics are taken from 2314 births 
which occurred at the Sloan Maternity Hospital before 
there had been no incubator in use. 

Four hundred and ten of these babies were prema- 
ture, but of these 74 were still-births, which include mac- 
erated foetus, and still-born babies of cases of placenta 
praevia, accidental haemorrhage, eclampsia, and the like, 
leaving 336 for treatment. 

Among these cases were a set of triplets, and there 
were 18 pairs of twins; 85 were treated as infants at term, 
and of these 4 died,— a mortality of 4 ^/^ per cent.; 145 



192 INFANT-FEEDING. 

were put in cotton^ and of these 12 died, — a mortality of 
8 per cent. Some of this class should have been placed in 
the incubator, but for lack of room it was impossible; 106 
were incubator babies. 

These are divided into two classes: 1. Those that died 
within four days of birth. 2. Those that lived longer than 
four days. 

Twenty-nine of the incubator babies died within four 
days. All of these but 3 were more or less asphyxiated at 
birth; 9 were breech cases, and of these 5 were difficult 
extractions; 3 after an accoucliement force in placenta 
prsevia. The rest were vertex presentations, but of these 
2 were forceps deliveries; 6 were under 7 months of. uter- 
ine gestation; 22 were betAveen 7 and 8 months along, and 
1, 8 V4 months. 

The etiology of the premature labor was an endo- 
metritis in 14; syphilis in 2; albuminuria in 1; placenta 
praevia in 3; accidental haemorrhage in 1; persistent 
vomiting in 1; twin in 1; violence in 1; and in 4 the 
labor was induced. The largest baby weighed 5 ^/^e 
pounds; the smallest 2 V^g pounds. Only 5 infants lived 
over twenty-four hours; 24 were in such poor condition 
at birth that they survived only a few hours. In 16 autop- 
sies were held, and in all of these there were marked 
atelectasis; in 7 haemorrhages of some degree, either into 
the brain or into the serous membranes; in 2 the foramen 
ovale was still patent. 

Seventy-seven incubator infants survived the first 
four days; 51 were children of primiparae, 27 of whom 
were out of wedlock; 3 infants were under 7 months of 
gestation, 8 were over 8 months along; 9 were breech 
presentations; 1 a transverse and the rest vertices; 2 
were of triplets associated with albuminuria; 18 were in 



INCUBATOR-FEEDING. 



193 




194 INEANT-FEEDIJvT^. 

twin deliveries, associated with all)uniiiiuria or livdraiii- 
uios. The cause of the premature labor was endometritis 
in 27; syphilis in 4; phthisis in 2; albuminnria in 7; ac- 
cidental hasmorrhage in 1; placenta prsevia in 1; in 2 the 
labor was indnced for albuminuria and eclampsia; 1 was a 
Csesarean section; another an ectopic gestation; the cause 
of the rest was unknown. Seven were delivered by for- 
ceps; 2 by a version; 1 by accoucliement force; 1 by Ce- 
sarean section, and the ectopic gestation by a laparotomy; 
12 were slightly asphyxiated at birth; 9 moderately so, 
and 5 deeply asphyxiated; 2, after one and a half hours' 
work of resuscitation, Avere pnt in the incubator head 
downward, and their condition was so poor that they were 
expected soon to die^ bnt they left the hospital gaining in 
weight; 5 w^eighed less than 3 pounds; 38 between 3 and 
4 pounds; 33 between 4 and 5 pounds; 1 over 5 pounds; 
the average w- eight was 3 ^-/^g pounds. During their in- 
cnbator-life 28 had one or more attacks of atelectasis. All 
but 10 were more or less jaundiced. The initial loss of 
the infants was from 1 to 17 ^/s ounces; the average was 
7 ounces. These figures are not quite correct, as the 
babies were weighed at different intervals, some on the 
fifth day, some on the seventh day, and others not till the 
fourteenth day. 

The period of loss was from five to twenty-t\vo days, 
the average, eleven days; 10 lost steadily till death; one 
baby was in the incubator only three days, while anothei' 
lived there eighty-two days. The average time was nine- 
teen days. Some were removed early to make room for 
others who needed the place more urgently. 

Only 3 of the 77 cases vomited. The stools were nor- 
mal in 32. 

One was discharged from the hospital as early as the 



IXCUBATOR-FEEDING. 195 

eleveiitli day, and others als(3 too soou at tlieir motliers" 
demand. One was 89 days old; the average was 24 days. 
In 16 diluted breast-milk was supplemented^ at times^ 
with a mixture of cows' milk and water, with Eiissian 
gelatin and lactose. In 10 a 1, 6. 0.33 modification was 
used. In all the rest diluted breast-milk was relied upon. 
Twenty-seven never nursed at the breast; of these, 12 
died. A few nursed as early as the third or fourth day 
two or three times a day. Others not for three weeks, and 
one not till the sixty-eighth day. Of the 77, 13 died in 
the hospital: a mortality of 16 per cent. The cause of 
death was atelectasis and bronchitis in 7, acute asphyxia 
from a curd in the larynx in 1, syphilitic pneumonia in 
1, cerebral haemorrhage in 1, gastro-enteritis in 3, and a 
patent foramen ovale and ductus arteriosus in 1. The 
condition of 3 was poor at time of discharge, fair in 24, 
and very good in 37; 32 were above their birth-weights. 
and 57 were gaining in weight. To letters written about 
January 1, 1900, no answer was obtained from 28. Thir- 
teen were reported as having died. 1 of these lived four- 
teen months, 1 nine months, 1 four and one-half months. 
'3 lived two months, 6 lived six weeks. 1 only a month. 
Five of these died at the Xursery and ChikVs Hospital, 
and 2 died at Bellevue Hospital. They were bottle-fed, 
and the probable cause of death was gastro-enteritis. 
Twenty-one were found to be alive and doing well. Some 
had nursed and the others were bottle-fed. The oldest 
baby was twenty-two months, and almost all were good, 
healthy children. One baby at seven months weighed 16 
])ounds. It weighed 4 ^/^p^ pounds at birth, and nursed from 
its mother after leaving the hospital. The ectopic and the 
Caesarean babies were in beautiful condition. 



196 



INFANT-FEEDING. 



INCUBATOKS. 



Saved at 6 months. 
Saved at 6h months. 
Saved at 7 months. 
Saved at 7^ months. 
Saved at 8 months. 



Takniek. Chaklks. 

Per Pek 

Cent. Cent. 



16 
36 
49 

77 
88 



10 

20 
40 

75 



Si.OANE 

Hospital 

Per 

Cent. 



22 
41 
75 
70 



At the SiiOANifi 
Hospital, not 

Counting 

those wh'ch 

Died IN A Few 

Hours 

Per Cent. 



66 
71 

89 
91 



The incubator here described (see ilhistration^ Fig. 
35) is the one used at the Sloane Maternity Hospital. 
There are a great variety of these incubators, but the one 
made by the Kny-Scheerer Company in this city will 
answer all requirements. Owing to its expense, the manu- 
facturers will lend an incubator for a nominal sum per 
month. 



CHAPTEE XXVIII. 

Aeeated Milk. 

Aeration of Milk. — Milk when drawn from the cow 
contains a certain amount of dissolved gases. These 
gases contain more or less of what is known as animal 
odor^ the amount of this odor depending very largely upon 
the physical condition of the animal at the time the milk 
is drawn. Sometimes the amount is very slight and 
scarcely noticeable; at other times it is so great as to be 
extremely offensive. These gases and the accompanying 
odor are easily removed from the milk by exposure of the 
milk to the air during the process of cooling, and to this 
extent aeration of the milk is an advantage. Various 
forms of aerators and combined aerators and coolers have 
been devised, many of which are simple and effective, and 
the best results follow their use. In order to secure these 
results by aeration, however, it is necessary that the ap- 
paratus used for aeration should expose the milk thor- 
oughly to the air, should not be cumbersome, and should 
be simple and easily cleaned; moreover, the process of 
aeration should always take place in the purest atmos- 
phere possible. 

Certified Milk. 
Dr. H. L. Coit organized a medical commission in 
Xewark, X. J., which has made agreements with the dairy- 
men compelling them to look after the details pertaining 
to the food, the selection of the cows, and — most particu- 
larly — the handling of the milk. All this is under the 
supervision of the Medical Commission. A veterinary 

(197) 



198 INFANT-FEEDING. 

surgeon is employed for the inspection of the animals. In 
like manner a chemist and bacteriologist see that the milk 
is kept to the standard requirements of composition and 
purity. The milk is delivered in bottles^ which are labeled 
"Certified Milk."' This plan has proved to be very suc- 
cessful, and certainly deserves imitation. 



CHAPTER XXIX. 

Infaxt-foods. 

Theee have been a great number of infant-foods and 
seemingly a great variety placed upon the market and ex- 
ploited by the makers as suitable for the artificial feeding 
of infants. 

These infant-foods may be broadly classified under 
two heads of (A) infant-foods in which cows' milk desic- 




Fig. 36. — Feeding-cup, after Period of Weaning. 



eated is a constituent, and (B) infant-foods to be used 
with and as adjuncts to fresh cows' milk. 

The infant-foods of which dried milk is a constituen^ 
are made from cereals and cows' milk. The milk is desic- 
cated in the process of manufacture, and these foods are 
commonly known as dried-milk foods, although in this 
class of foods milk-solids constitute but from one-eighth 

(199)^ 



200 INFANT-FEEDING. 

to one-fourth the substance of the foods, the balance con- 
sisting of matters derived from cereals. In some of these 
foods the starch of the cereals is untransf ormed, and they 
may be termed farinaceous dried-milk foods. In others 
the starch of the cereals has been transformed into dex- 
trin and maltose, and they may be termed malted dried- 
milk foods. 

All attempts to preserve whole cows' milk by evapo- 
rating it to dryness have been failures; the fat of desic- 
cated milk soon acquires a rancid flavor, and the caseous 
matter does not properly dissolve in water, as the drying 
process destroys its colloidal condition. In the dried- 
milk foods the caseous matter of the cows' milk is inti- 
mately mixed with the other ingredients, but its colloidal 
condition has been destroyed, and it is in the form of fine, 
hard, granular particles, very sparingly soluble in water. 

The group of infant-foods used as adjuncts to cows' 
milk are either farinaceous foods, .made from cereals and 
consisting largely of unconverted starch; or malted foods, 
also made from cereals, but having the starch transformed 
into soluble maltose and dextrin. As fresh cows' milk is, 
without doubt, the best generally-available material for 
the artificial feeding of infants, the foods of the latter 
class, used for the modification of fresh cows' milk, are 
more in accord with physiological principles than are the 
dried-milk foods. 

Of the large number of infant-foods that have been 
put on the market, it is our purpose to describe a few 
commonly-known foods. In order to judge fairly of the 
nutritive value of an infant-food and its resemblance to 
woman's milk, it is necessary to know its composition 
after its preparation for the nursing-bottle according to 
the directions of its manufacturer, and the analyses that 



IJ^FANT-FOODS. 301 

accompany the following descriptions are of the foods pre- 
pared for nse for infants six months of age as per direc- 
tions on the packages. 

The published analyses of womair's milk show the 
great variability of its composition^ especially as re- 
gards the percentages of proteids and fats. The analysis 
of woman's milk nsed in the following tables is by Dr. 
Luff, adopted as the standard by Cheadle. It agrees 
closely with Leeds's analysis, excepting as to the fat, 
which is given by Lnff as 2.41 per cent, and by Leeds as 
4.13 per cent.; the latter amount seems too large, as it 
considerably exceeds the published averages of a number 
of observers. 

nestle's food. 

N"estle's food is a farinaceous dried-milk food of Class 
A. According to the manufacturers, it is made "from 
the richest and purest cows' milk, the crust of wheaten 
bread, and cane-sugar," and is a "form of modified milk." 
"N"o cows' milk is to be added to I^estle's food; nothing 
but water, and that water is boiled." 

Upon examination, unconverted starch and cane- 
sugar are found to be its principal constituents, amount- 
ing to about 70 per cent, of the whole. The directions 
for preparing Nestle's food for the nursing-bottle, for in- 
fants six months old, are to use 2 level tablespoonfuls of 
the food to ^/o pint of water; mix the food wdth enough 
warm water to make a smooth paste that will pour, add 
the rest of the water and boil in a sauce-pan, stirring con- 
stantly until it thickens and a milky foam appears on the 
top. 



,vH)2 INFANT-FEEDING. 

Composition of Nestle's 

Food," ivhen Prepared 

as Above. Womaws Milk. 

Water 92.76 88.51 • 

Salts 0.13 0.34 

Proteids 0.81 2.35 

Fat 0.36 2.41 

Starch 1.99 

Cane-sugar 2.57 

]\laltose, dextrin, etc 0.44 

Milk-sugar 0.84 6.39 

Reaction alkaline. Reaction alkaline. 

The thick condition of the mixture is owed mainh' 
to the insoluble starch present. The total carbohydrates 
therein (5.84 per cent.) are somewhat less than the carbo- 
hydrate^ milk-sugar (6.39 per cent.)^ in woman^s milk; it 
is to be noted that^ of this amount^ 1.99 per cent., or 
about one-third, consists of insoluble starch. 

The fat is nearly one-sixth and the proteids are about 
one-third of the amounts in woman's milk, and over one- 
half of the proteids is insoluble, owing to the colloidal 
condition of the milk-casein having been destroyed by 
drying during manufacture. 

horlick's malted milk. 

This is a malted dried-milk food of Class A, stated on 
the circulars to be composed of pure, rich cows' milk com- 
bined with an extract of malted grain, and not to require 
the addition of cows' milk. Its makers claim that, by 
special treatment with their new agent, plant-pepsin, the 
casein, or cheesy part, of the cows' milk is kept from form- 
ing large and irritating curds in the stomach. 

This food is very nearly soluble in water, as its prin- 



*~ According to Chittenden. 



INFANT-FOODS. 203 

cipal constituents are the soluble carbohydrates — maltose, 
dextrin, and milk-sugar. The drying process has de- 
stroyed the colloidal condition of the caseous matter of 
the milk, and it is in the form of finely powdered, hard 
particles, sparingly soluble in Avater. 

The directions for preparing the food for an infant 
six to twelve months of age are to dissolve 4 to 6 tea- 
spoonfuls in V2 pint of water. Composition when pre- 
pared by using 6 teaspoonfuls of food to ^/o pint of water: 

Horlick's Malted Milk.*^ Woman's Milk. 

AVater 92.47 88.51 

Salts 0.29 0.34 

Proteids 1.15 2.35 

Fat 0.68 2.41 

Maltose and dextrin 4.20 

Milk-sugar 1.18 6.39 

Reaction alkaline. Reaction alkaline. 

The proteids, fat, and carbohydrates are all less than 
in w^oman's milk, the proteids being not quite one-half 
and the fat not quite one-third of the amounts in woman's 
milk. The amount of milk employed must be very small 
in proportion to the cereal constituents, since the mixt- 
ure, prepared as above, corresponds to a dilution of 1 
part of good cows' milk with about 4 parts of water. 

MILKINE. 

This is a malted dried-milk food (Class A). Its 
makers state it is a complete food ready for immediate 
use by the addition of water, and the only prepared food 
that combines the nutritive elements of meat, milk, and 
cereals. 



According to Chittenden. 



204 INFANT-FEEDING. 

In this malted dried-milk food beef-extract is com- 
bined with cereal extractives and dried milk. Soluble car- 
bohydrates are its principal constituents^ forming nearly 
three-fourths of the product. The proteids are sparingly 
soluble. 

The directions for preparing milkine for an infant 
three to six months of -age are to dissolve 1 to 2 dessert- 
spoonfuls of food in a breakfastcupful of water. 

Composition when prepared with 2 dessertspoonfuls 
in a breakfastcupful of water: — 

Milkine. Woman's Mill\ 

Water . 92.78 88.51 

Salts 0.23 0.34 

Proteids 0.92 2.35 

Fat 0.43 2.41 

Maltose, dextrin, etc 4.74 

Milk-sugar 0.90 6.39 

Reaction alkaline. Reaction alkaline. 

The total solids are hardly two-thirds of the amount 
in woman's milk. The fat especially is greatly deficient, 
being only about one-sixth of the amount in woman^s milk, 
and the proteids are but two-fifths of the amount in 
woman's milk. 

A dilution of 1 part of good cows" milk with about 7 
parts of water will contain about the same amount of milk 
as milkine prepared as above. 

CEREAL MILK. 

Cereal milk is a malted dried-milk food (Class A). It 
is stated by its makers to be a complete food, cooked and 
ready for use with the simple addition of water, and to 
be made from the purest Vermont dairy-milk, the finest 
wheat-ghiten flour, the best barley-malt, and milk-sugar. 



INFANT-FOODS. 205 

Cereal milk in general appearance very mucli re- 
sembles the other malted dried-milk foods, but it contains 
a much greater percentage of milk-sugar, showing that 
this substance is used in its manufacture, as claimed. 

The directions for preparing it for use are to mix 1 
teaspoonful of cereal milk in a teacupful of hot water 
for infants under three months of age or for a very deli- 
cate child. For older and stronger children 1 to 3 tea- 
spoonfuls of food are to be used to each cupful of water. 
Composition when prepared by using 2 heaping tea spoon- 
fuls of food to a teacupful of water:— 

Cereal Milk. Woman's Milk. 

Water 92.52 88.51 

Salts 0.16 0.34 

Proteids 0.69 2.35 

Fat 0.30 2.41 

Maltose, dextrin, etc 4.73 

Milk-sugar 1.60 6.39 

Reaction alkaline. Keactiou alkaline. 

The total of soluble carbohydrates as above is prac- 
tically the same as in woman's milk; the amount of pro- 
teids is less than one-third the amount in woman's milk, 
and about one-half is insoluble in water. The amount of 
fat is one-eighth the amount in woman's milk. The small 
amount of fat indicates that the cereal extractives and 
milk-sugar make up the bulk of the solids of this food, 
and that a dilution of 1 part of good cows' milk with 
11 parts of water would be the counterpart of the above 
mixture as to the amount of milk therein. 

wampole's milk-food. 

Wampole's milk-food is a malted dried-milk food 
(Class A). Its makers state that it is made from malted 



206 INFANT-FEEDING. 

cereals, beef, and milk, and when mixed with warm water 
it is immediately ready for nse; no other preparation 
necessary. 

This dried-milk food is very nearly soluble in water, 
owing to the soluble carbohydrates being so large a con- 
stituent. A little less than one-half of the proteids is in- 
sohible in water. A small amonnt of beef-extract has been 
combined with the cereal extractives and dried milk. 

To i^repare it for an infant six months to one year of 
age, the directions are to dissolve -i to 6 teaspoonfuls of 
the food in 6 onnces of hot water. Composition when 
prepared by dissolving 6 teaspoonfnls in 6 ounces of water: 

Wampole's Milk-food. Woman's Millc. 

Water 88.59 88.51 

Salts 0.46 0.34 

Proteids 1.58 2.35 

Pat 0.73 2.41 

Maltose, dextrin, etc 7.65 

Milk-sugar 0.99 6.39 

Reaction alkaline. Reaction alkaline. 

Compared with woman's milk it is seen that the car- 
bohydrates are considerably in excess, and the proteids 
and fat are deficient, the fat especially, it being less than 
one-third the amount in woman's milk. 

One part of good cows' milk diluted with about 3 ^A 
parts of water would be analogous to the dilution of milk 
in Wampole's milk-food prepared as above. 

IMPERIAL GEANUM. 

Imperial graiium is a farinaceous food to be used as 
an adjunct to cows' milk (Class B). 

Its makers state that it is a solid extract derived from 
very superior growths of wheat, nothing more. It ap- 



IXFAXT-FOODS. 20T 

pears to be made as elaimed from wlieateu flour and to 
l)e mainly composed of torrefied starch. 

For an infant six months of age it is to be prepared 
by cooking 3 ^/o teaspoonfnls of food in 21 ounces of water 
andt 20 ounces of milk. 

Composition when prepared as above: — 

Imperial Granum.^'^ Woman's Milk. 

Water 91.53 88.51 

Salts 0.34 0.34 

Proteids 2.15 2.35 

Fat 1.54 2.41 

Starcli 1.22 

Maltose, dextrin, etc 0.58 

Milk-sugar 2.71 6.39 

Reaction alkaline. Reaction alkaline. 

The total of solids contained is one-quarter less than 
in woman's milk: the carbohydrates are nearly one-third 
less than the amount in woman's milk and it should be 
observed that 1.22 per cent., or about one-fourth of them, 
consist of starch; there is only a slight deficiency in the 
amount of proteids, but a considerable deficiency in the 
amount of fat. By using more milk or milk and cream 
and less water than above employed the percentages of 
fat, proteids, and soluble carbohydrates would be in- 
creased. 

Its very large proportion of starch forms the principal 
objection to this food. 

The presence of unconverted starch causes the thick 
condition of the mixture. 

ESKAT^S ALBUMENIZED FOOD. 

This food is to be prepared with cows' milk (Class B). 
Its makers state that it contains the more easily di- 
gested cereals combined with egg-albumin. 



According to Chittenden. 



208 INFANT-FEEDING. 

Eska3^"s albiimenized food consists largely (about 88 
per cent.) of carbohydrates; the soluble carbohydrates, 
mostly milk-sugar, are about 50 per cent, and the in- 
soluble carbohydrates, mostly starch, are a little less than 
-iO pep cent. On account of this large proportion of starch 
it may be termed a farinaceous food. 

It contains about 5 V^ per cent, of proteids, and they 
are almost entirely insoluble in water. 

If, as claimed, egg-albumin is a constituent of the 
food, it is apparently coagulated and made insoluble in 
the process of drying. However, did the product contain 
egg-albumin carefully desiccated and soluble, it Avould be 
coagulated and rendered insoluble in preparing the food 
for use, as the temperature directed to be employed is 
considerably above that at which normal egg-albumin is 
coagulated. 

The directions for preparing it for an infant from 
six to twelve months of age are to cook 3 tablespoonfiils 
of the food in 2 ^/^ pints of water and 9 tablespoonfiils of 
cows' milk and add thereto 6 tablespoonfuls of cream. 
Composition when prepared as above: — 

E shay's Alhumenized 

Food. Woman's Milk. 

Water 92.16 88.51 

Salts 0.16 0.34 

Proteids 0.85 2.35 

Fat 3.11 2.41 

Starch 1.03 

Dextrin, etc 0.47 

Milk-sugar 2.22 6.39 

Reaction alkaline. Reaction alkaline. 

The total carbohydrates are three-fifths of the 
amount in woman's milk; of these nearly one-third is un- 



INFANT-FOODS. 209 

converted starch. The proteids are greatly deficient^ be- 
ing only two-fifths of the amount in woman^s milk. The 
fat^ from the use of so mnch cream, is somewhat in excess. 
The prepared food, it is to be seen, falls far below woman^s 
milk in its nntritive constituents. 

mellin's food. 

Mellin^s food is a malted cereal food (Class B). This 
food is stated by its makers to be a soluble dry extract 
from wheat and malt, for the modification of fresh cows' 
milk. 

The carbohydrates therein are in the form of dextrin 
and maltose, and constitute about 80 per cent, of the 
food; the proteids amount to about 10 per cent., and are 
derived from the cereals. Mellin's food is almost com- 
pletely soluble in water. It is especially noticeable that 
this food does not contain any starch. 

The directions for preparing this food for use for in- 
fants six months of age and over are to dissolve 2 heaping 
tablespoonfuls of food in ^/^ pint of hot water and ^/^ 
pint of cows' milk. 

Composition when prepared as above: — 

MelUn's Food.^° Woman's Milk. 

Water ' 88.00 88.51 

Salts 0.47 0.34 

Proteids 2.62 2.35 

Fat 2.89 2.41 

Maltose, dextrin, etc 2.73 

Milk-sugar 3.25 6.39 

Eeaetion alkaline. Reaction alkaline. 

In total solids this food difi^ers but slightly from 
Avoman's milk, and in the various constituents its simili- 



According to Chittenden. 

14 



210 



INFANT-FEEDING 



tude to woman's milk is remarkably close. Of tlie carbo- 
hydrates the maltose ami dextrin are a little less in 
amount than the milk-sugar^ and the total carbohydrates 
(5.98 per cent.) are only slightly less than the amount in 
woman's milk. 

The manufacturers of Mellin's food present many 
formulas for preparing the food for use to meet various 
indications. The following formulas are given with the 
analyses of the respective milk-modifications: — 



FoRMUi..^ AND Analyses foe Preparing Melltn's Food. 
For Infarits ahout Two Months Old. 



1 
Mellin's food, tea- 
spoonfuls (level). { Gives this 
Milk, 6 V2 fluidounces. f composition ; 
Water, 9 V- fluidounces. 

J 



Water 93.40 

Salts 0.35 

Proteids 1.69 

Fat . 1.53 

Carbohydrates (no 
starch) 3.03 



Low Proteids. 



Mellin's food, 2 table- 1 
spoonfuls (heaping). 

Milk, 4 fluidounces. 1 

Cream, 1 ^/o tablespoon- [ 
fuls. I 

Water, 12 fluidounces. j 



Gives this 
composition : 



r Water 91.50 

I Salts 0.37 

I Proteids . 1.45 

I Fat 2.50 

j Car-bohydrates (no 

I 



starch) 4.18 



High Fat and Low Proteids. 



Mellin's food, 3 table- 
spoonfuls (heaping). 
jVOlk, 4 fluidounces. 
Cream, 2 tablespoonfuls. 
Water. 12 fluidounces. 



I Water 89.36 

I Salts 0.45 

Gives this 1 Proteids 1.65 

composition: j Fat 3.00 

Carbohydrates (no 
starch) 5.54 



INFANT-FOODS. ^ 211 

PEPTOGENIC MILK-POWDER. 

This product is stated by its makers to be an article 
contaiiiiiig milk-sugar and a digestive ferment -capable of 
acting on casein, offered for the preparation of an arti- 
ficial infant-food. McGill states: "It is not, in the strict 
sense, a food. Its professed object is so to change the 
compositio]! of cows' milk as to render this comparable 
to human milk. This it seeks to do by introducing milk- 
sugar and small quantities of albuminoids. '^ - According to 
McGrill's analysis, it is composed almost entirely of milk- 
sugar (96.60 per cent.). 

The following analysis is by Leeds, and is taken from 
a circular of the makers. 

Composition of /'humanized milk"' prepared as di- 
rected, using 4 measures of peptogenic milk-powder with 
^/o pint of milk, \/o pint of water, and 4 tablespoonfuls of 
cream: — 

Humanized Milk. Woinan's Milk. 

Water 86.20 88.51 

Ash 0.30 0.34 

Proteids 2.00 2.35 

Fat 4.50 2.41 

Milk-sugar 7.00 6.39 

Heaetion alkaline. Reaction alkaline. 

Chittenden's analysis of this "humanized milk"" is al- 
most identical with the above. 

The proteids of the cows' milk undergo a change in 
the peptonizing process, being converted chiefly into par- 
tial peptones, and in this form they cannot be said to re- 
semble the proteids of woman's milk, which have not been 
acted upon by a proteolytic ferment. 



CHAPTER XXX. 

Condensed Milk. 

• 

As CONDENSED milks are yqtj widely employed for the 
artificial feeding of infants, the analyses of a few well- 
known brands are given prepared for this purpose by di- 
Inting with water. These condensed milks contain large 
amounts of cane-sugar, added on account of its preserva- 
tive qualities. 

The directions on the tin of the Anglo-Swiss Con- 
densed Milk Company's Milkmaid Brand of condensed 
milk are, for newborn infants, add 14 parts of water; as 
the child grows older, gradually use less water, but never 
less than 7 parts. 

The analyses of all these condensed milks are of the 
milk diluted with both 7 parts and 14 parts of water — the 
two extremes. 

Gail-Borden Eagle 
Millcmaid Brand. Brand. 

With 7 With 14 With 7 W^ith 14 

Pts. Water. Pts. Water. Pts. Water, Pts. W^ater. 

Water 88.18 93.59 89.10 94.09 

Ash 0.36 0.19 0.29 0.16 

Proteids 1.50 0.82 1.31 0.71 

Fat 1.70 0.92 1.18 0.64 

Cane-sugar 6.00 3.25 6.59 3.57 

Milk-sugar 2.26 1.23 1.53 0.83 

Nestle's Sioiss Milk. Woman's ^Lill-. 

Wi-h7 Wi'hl4 

Pt> Water. Prs. Water. 

Water 87.95 93.46 88.51 

Ash 0.25 0.14 0.34 

Proteids 1.51 0.82 2.35 

Fat 2.14 1.16 2.41 

Cane-sugar 5.81 3.15 

Milk-sugar 2.34 1.27 6.39 

(212) 



GAEKTXEK MOTHEE-:\IILK. 213 

The foregoing brands of condensed milks are consid- 
ered to be among the 1)est npon the market. 

Professor Gaertxer Mother-milk. 

In a paper entitled ""The Clinical Value and Chem- 
ical Eesults'' the author published a paper in the Medical 
Record, December 11, 189T. This new food has now been 
used about fiye years in Enrope, and is the outcome of 
the scientific endeavors of Professor Gaertner, of the Uni- 
versity of Vienna. The first paper was piiblished by 
Gaertner in tl}e Therapeutische ^yoc]lenscJl7^ift, May 5, 1895. 

A few months before, January, 1895, Gaertner, in an 
address before the Vienna Scientific Society, explained 
the mode of preparation and the results obtained with 
his new modification of cows' milk, for such the mother- 
milk of Gaertner really is. Professor Gaertner, in the 
preparation ol his food, has aimed to overcome wdiat has 
been the great difficulty in infant-feeding — namely: to 
reduce the excess of casein by a scientific process without 
the addition of chemicals. 

To achieve this resnlt he employs a machine called a 
separator or pfankauser centrifuge, which makes four 
thousand or eight thonsand revolutions per minnte. The 
apparatus consists essentially of a drum of steel, which re- 
volves on its axis. ' This drum is filled with equal parts of 
fresh cows' milk and sterilized water. The mixture con- 
tains approximately the same amount of casein as human 
milk, for cows' milk undiluted contains about twice as 
much casein as human milk. The mixture is next poured 
into the centrifuge and the speed of the drum is carefully 
regulated, so as to separate the mixture contained therein 
into (1) a creamy (fatty) milk and (2) a skimmed milk. 



214 INEA NT-FEEDING. 

The two portions so separated are then led oft' separately 
by suitable openings in the centrifuge. 

The analysis of each of these portions shows that the 
creamy milk has the same quantity of fat as is found in 
human milk, whik^ about 2 per cent, of the casein is con- 
tained in the skim-milk, and the remainder, about 1.7 per 
cent., remains in the creamy milk. The chemical com- 
position of fat milk is shown in the following table: — 

Froteid. Fat. Sugar. Ash. 

Eat milk 1.76 3-3.5 2.5 0.35 

Human milk 1.03 3.5 7.03 0.21 

Cows' milk diluted with one- § 

half water 1.76 1.6 2.5 0.35 

If, now, 3 or 4 grammes of milk-sugar be added to 
every 100 cubic centimetres of fat milk, the percentage 
of sugar is brought up to the level of sugar in human 
milk. This addition is made before sterilizing. The fat 
milk has the advantage over the diluted milk of having 
"a higher percentage of fat," and also it curdles more 
slowly than diluted milk and the curd forms a more floc- 
culent precipitate. 

According to Escherich, the following amounts 
should be used at different ages of infancy, feeding every 
two to four hours: — 

Infants under 2 weeks ... . 500 corns. (17Vn 5) in 9 feedings. 

Infants 3 to 4 weeks 750 c.cms. (26 3) in 8 feedings. 

Infants 4 to 8 weeks 1,000 c.cms. (35 S) in 8 feedings. 

Infants 3 to 4 months. . . .1,250 c.cms. (42 S) in 8 feedings. 

Infants 5 to 6 months. . . .1,500 c.cms. (50 ^) in 7 feedings. 

Escherich gives in detail his experience in feeding 
with fat milk fifty infants in a hospital, including rickety 
and tuberculous children. He has certainly met with 



GAEETNER MOTHER-MILK. 215 

marked success. Some cases have been under observation 
for six months. His article is published m extenso in 
Mitteilungen cles Vereim der Aerzte in Steiennarh, N"o. 1, 
1895. 

Baginsky"^ mentions Claertner milk as a new form 
of food introduced. In our country Jacobi'^- states that 
(xaertner milk is applicable to the majority of infants who 
require cows' milk appropriately prepared. 

During the last summer I proposed to test the effi- 
cacy of Gaertner milk. With this view I have subjected 
the milk to a very rigid test, inasmuch as the time chosen, 
from June to October, was the heated term, which is the 
worst for milk digestion, and the hygienic conditions of 
the infants were those found in the average tenement- 
house, too Avell known to need description. 

The guides for ascertaining the degree of assimila- 
tion were the following factors: — 

1. The child's general condition, as manifested by its 
appearance, appetite, and sleep. 

2. The presence or absence of gastro-enteric disturb- 
ances, such as vomiting, colic, restlessness. 

3. The condition of the stools, constipation or diar- 
rhoea, the number of stools in twenty-four hours. 

4. The gain in weight; weekly observations. 

The nurses or mothers were instructed to note the 
amount of food taken and the number of stools in twenty- 
four hours. 

We submitted the stools passed in twenty-four hours 
to Mr. Herman Poole, our chemist, whose chemical re- 



•''^ '•Tjehrbuch der Kinderkrankheiten."' fifth edition, pages 35 
and 36. 

'■- "Thevapentics of Infancy and Childhood," page 508. 



216 INFANT-FEEDING. 

port is appended. Thus we have tried to ascertain hoM^ 
much proteids^ fat, sugar, and salts were taken, how much 
absorbed, and how much was voided in the faeces without 
having taken part in metabolism. 

The following cases will serve to illustrate the 
method pursued in attempting to solve the problem be- 
fore us and the results obtained as regards the efficacy of 
the milk: — 

Case I. — Dorothy Shattuck, a prematurely-born child, the 
labor having occurred in the middle of the eighth month of gesta- 
tion. For three weeks after birth the child's mother fed her on 
Borden's "eagle brand" condensed milk, and then, being discour- 
aged with the results, gave the child to the care of Mrs. Turnure, 
■who brought her to the clinic. For the past week she had fed the 
child on malted milk and a mixture of milk, cream, and barley- 
water. June 16, 1897, the little patient first came to us at the 
German Poliklinik. She stated that the child had been getting 
worse, was extremely irritable, slept badly, had had persistent 
vomiting and diarrhoea, with six and more watery stools daily. 
It also had a hacking cough. 

Status prcesens: An extremely-emaciated child, twelve weeks 
old, weighing 6 pounds and 12 ounces. The head is of normal 
shape; the face has a peculiar, senile expression; the fontanelles 
are open, but do not bulge. The scalp is of a reddish color, with 
here and there a furuncle. The face has a sallow, earthy color; 
the eyes are kept closed most of the time. The thorax is not de- 
formed; the ribs are not beaded; the thoracic skeleton is sharply 
outlined; the skin is dry, yellowish. The upper extremities show 
thick epiphyses; thin, flabby, bluish skin; cojd, weak hands; and 
thin, atrophic long bones. The reflexes are diminished, the grasp 
is weak. The abdomen is full and pendulous, the abdominal walls 
are very thin, the intestines are distended with gas. The skin in 
the groins is flabby; there are no dilated veins and no hernise. 
The buttocks and genitals are covered with an erythematous rash 
(intertrigo); the anal reflex is normal; rectal temperature, 99° 
F. The lower limbs are similar to the upper — thin bones, thick 
epiphyses, atrophic muscles, bluish dry skin. The scapulae project 



GAEETNER MOTHEE-MILK. 217 

behind; the spine is not deformed; the whole appearance is one 
of extreme atrophy. The tongue has a Avhite coating; gums 
normal; fcetor ex ore. There are swollen glands in the inguinal 
region and furuncles on the thighs. The child drinks water with 
avidity; a peculiar^ lactic-acid smell is exhaled from the body. 

Diagnosis : Athrepsia, catarrhus gastro-entericus, rachitis. 

Treatment: («) Hygienic: Daily baths; cleanliness in the 
mouth, clothing, bottles, nipples. 

(6) Dietetic: The sole diet, Gaertner's mother-milk. Three 
cans (one-third litre in each) in twenty-four hours; beginning with 
a few ounces at a time, and increasing the dose gradually until 8 
ounces are given at one mealj, of which there should be six in 
twenty-four hours: i.e., every three hours in the day-time and at 
longer intervals at night. 

(c) Medicinal: None. 

An iri'igation with hot water was used to wash out the colon 
and rectum before the diet was begun. 

June 23d, the child took the milk at first reluctantly; the 
first doses were vomited at once. The nurse persisted, however, 
and her efforts were rewarded, for in a few hours the baby began to 
take the milk in larger quantities and to retain it well. The vomit- 
ing and diarrhoea stopped — three stools daily. The child was quiet, 
and slept twelve to sixteen hours out of twenty-four. Looked 
cleaner and brighter. 

June 26th. The general condition is the same; bowels reg- 
ular, tongue clean, complexion more natural. 

On July 14th the weight was 8 pounds and 3 ounces, a 
gain of 1 pound and 10 ounces in two weeks; 26 ounces in 
fifteen days equals 1 -/s ounces daily gain. The milk was continued 
in the same quantities; a fresh supply was furnished at the clinic 
on every visit. The child was seen two or three times every week. 

July 29th. Weight, 8 pounds and 10 ounces. Gained a ounces 
in fifteen days, or ^/o ounce daily out of the 48 ounces of milk con- 
sumed. 

August 4th. Had an attack of vomiting and diarrhcea, which 
was relieved by one dose of castor-oil. There are three or four 
stools daily. 

August 7th. Milk continued as usual. The child looks 
bright; face smooth and of a natural color. Sleeps well, appetite 
good. 



218 INFANT-FEEDING. 

August 14tli. For tlie last two days there is vomiting fol- 
lowing an attack of cough. Child takes her food well; mucous 
rales on both sides of the chest; temperature, 101° F. ; diagnosis 
of bronchitis. A teaspoonful everj^ three hours of mistura glycyr- 
rhizse composita, to which some belladonna had been added, relieved 
the cough. 

September 4th. The child has a normal temperature, cough 
is stopped, general condition is good, digestive organs are in good 
order. 

The child was not seen until September 20th. Weight, 10 
pounds and 14 ounces. The child is still taking the milk^- and ap- 
pears to enjoy very good health. 

Case II. — Abraham Friedmam 1 year old, Avas fed at the 
breast for the first seven weeks of his life. Since then he had been 
receiving condensed milk. On July 3d was first seen at the Ger- 
man Poliklinik, with the history of diarrhoea, twelve greenish stools 
a day, vomiting once or twice daily. 

On examination, a pale, bloated child; skin flabby, smooth, 
and dry; fontanelles open, dentition retarded, ribs beaded, abdo- 
men pendulous, limbs weak, and bones very thin. Weight, 17 
pounds and 10 ounces. 

Diagnosis : Gastro-enteritis, rachitis. 

Treatment: An irrigation of colon and rectum with a deci- 
normal saline solution: 5 grains of betanaphthol-bismuth every 
three hours. 

Diet: Gaertner milk, three or four cans daily, at intervals 
of three hours. 

On July 7th the general condition is better, no vomiting, two 
or three stools a day. 

July 14th. The condition remains the same. 

Ju#y 29th. No diarrhoea, no vomiting; has two stools a day. 

August 7th. The child's weight is 20 pounds and 10 ounces. 

September "Ml. The child receives, in addition to the mother- 
milk, soup and rice. The general appearance is better; two stools 
daily of a brownish-yellow color. The child was discharged cured. 

Case III. — Abraham Bassiek, 7 months old. first seen at the 
dispensary July 21st. Previous history: Born at term; for the 
first three days after birth he received the breast, and then he was 



J GAEKTXER MOTHER-MILK. 219 

fed ou coudensed milk. The child has an erythema intertrigo and 
lichen tropicus. Xoav suffers "with diarrhoea, vomiting, and colic. 
Child is considerably emaciated, and weighs S pounds and l-t 
ounces, including his clothes. 

Diagnosis: Athrepsia infantum. 

Prognosis doubtful. 

Treatment same as in Case I. Feeding: Xumber of cans 
daily, three: number of meals per day, six; at night, two. 

Clinical results: The child increased in weight: the condi- 
tion of the gastro-intestinal tract seemed to improve while he was 
taking this form of food: there was no vomiting nor diarrhoea for 
the first three days after the commencement of the feeding. The 
child was infected with measles on August 9th, and was removed 
from our observation. The child died of pneumonia, August 16th. 

Case IV. — Grace Bliss, 2 months old, was first seen August 
14th. Mother had a number of miscarriages. and lost several chil- 
di'en; has had several still-born children, some covered with an 
eruption. The present child was born at term, weight not known : 
has been nourished at the breast until to-day. For the past two 
weeks the child has been restless, cries a good deal; coughs, has 
coryza; also has eructations and passes a great deal of wind; 
three or four greenish slimy stools a day. 

The examination shows a iarge, square head, thick epiphyses, 
distended abdomen, beaded ribs, flabby skin. There are no erup- 
tions, and their existence previously is denied. The temperature 
is normal; no enlarged glands. Weight to-day. 11 pounds: the 
child has been losing weight gradually. 

Diagnosis: Athrepsia, rachitis, lues congenitalis. 

Treatment : The breast-feeding is to be alternated with Oaert- 
ner milk, one to one and one-half cans daily. 

The child was seen every other day until August 28th. Gen- 
eral condition good, take^ the milk readily, there is much less 
colic, the child seems more contented and more quiet; stools are 
yellowish and appear more normal in consistence. 

On September 1st the child's weight was 11 pounds and 11 
ounces: a gain of 11 ounces in two weeks. The child has been 
watched during the month of September, and has received small 
doses of calomel — Vio grain three times a day for its lues — besides 
a bichloride bath. 1 to 10.000. everv third or fourth nisht. 



220 INFANT-FEEDING. 

We consider this case very much improved. 

Case y. — Mary Burghardt, a premature child, born at the 
eighth month of utero-gestation. Mother reports that it weighed 
about two pounds {sic). It was first seen on the 1st of August. 
During the first week of life the child appeared fairly well, slept 
quietly, and took the breast without any signs of discomfort. The 
child is now eleven days old; we are told that it coughs, moans, 
and cries when touched. There are frequent soft stools. The child 
is about one and one-half feet long, and weighs three pounds. The 
mother states that she has lost several children in their infancy 
and had several miscarriages. 

Examination: The head is of normal shape, with the soft 
bones and open fontanelles at this age. The face has a senile ex- 
pression, but the skin is of normal color. There is no eruption; 
there are no beaded ribs. The upper extremities are very thin, the 
hands cold, the feet cold. The veins are enlarged; the abdomen is 
distended, tympanitic' on percussion. The mother states that the 
skin of the lower half of the body came off in large scales a few 
days after birth. The skin is dry and shrunken. Temperature, 
101.6° F.; pulse, 138. 

Treatment: Irrigation; calomel, Vio giain t. i. d. Gaertner 
milk, 2 ounces every three hours. 

The diagnosis of the case was congenital syphilis and 
athrepsia infantum. 

The child was reported considerably improved, but it was 
thought advisable not to increase the quantity of milk until the 
28th of August, when the child received V2 ounce more at each 
feeding. The child was watched during the month of September, 
and is considerably improved to-day. Weight, 4 pounds and 9 
ounces on September 25th. 

Owing to the coolness of the limbs, inunctions of oil were 
given every day following the bath, and the child's body was 
wrapped in cotton-wool. 

Besides the above cases we have had fifteen patients 
to whom Gaertner milk was given since the beginning 
of June last. In some cases it was necessary to add sngar 
to the milk, as many children objected to the taste. In 
one case (Case III) no deductions can be made, owing to 



GAERTNEE MOTHER-MILK. 221 

the cliilcVs infection with measles and pneumonia result- 
ing fatally. 

Cases I and Y serve as splendid illustrations for the 
proper determination of the value of this, food, as both 
were syphilitic and prematurely-born children. The 
other two children (Cases II and IV), although much 
stronger at the commencement of the treatment, im- 
proved very rapidly. We sometimes diluted the Gaert- 
ner milk with equal parts of barley- or rice- water, 
and if this latter mixture was not retained, then the 
Gaertner milk was discontinued. In the above cases 
the milk was borne very well, and is continued up to 
the present day. Although our experience is not so large 
as that of Professor Escherich, we feel that we can in- 
dorse both his statements and those of Professor Gaertner. 

The assimilation of this form of food, judging from 
the stools, is equal to that of any other modified milk. 
The German journals assert that rickets and scurvy can 
be prevented by using this milk. As our observations 
have not been carried on long enough, we cannot yet cor- 
roborate this. 

As we frequently notice that some children show a 
distinct idiosyncrasy when given milk, so it was in one 
case in which neither cows' milk, nor modified milk. 
nor breast-milk, nor Gaertner milk was tolerated. That 
child fared best on malted milk, properly diluted. 

Concltisions. — The small amount of proteid matter 
contained in the milk appeared to be very easily as- 
similated in the cases above mentioned. Case I is a 
splendid illustration of a tolerance of this form of feed- 
ing, when neither cows' milk, condensed milk, nor malted 
milk was retained. We felt greatly encouraged, especially 
in the very hot July days, to find this baby gaining in 



222 INFANT-FEEDING. 

weight, for it must be remembered that this chiki, in our 
city with poor hygienic surroundings, gained, from the 
end of June to the 14th of July, 26 ounces in fifteen days. 

Case II, suffering from summer compUiint about the 
same time, early in July, made very rapid progress, and 
while it could not digest a dilution of one-third milk and 
two-thirds barley-water without passing six or eight stools 
a day, fared very well on the Gaertner milk. 

Case III was under observation from July 21st until 
August 9th, and, although progressing favorably, unfortu- 
nately contracted measles and died. 

Case IV, an emaciated child, had been receiving 
breast-milk, which did not satisfy it. It frequently 
nursed from thirty to thirty-five minutes at the breast. 
The child's mother insisted on nursing it, and thus we 
gave mixed feeding, alternating the breast-milk with the 
Gaertner milk. Thus the child has received from two to 
three cans of milk per day, without showing any evidences 
of colic, and without having gastric or enteric disturb- 
ances. The treatment has been continued for over two 
months. 

Case V, the prematurely-born child with congenital 
syphilis, was certainly one which was well adapted for the 
trial of this form of feeding. When she was first seen 
there were thick, cheesy stools, which, after the gastro- 
intestinal tract had been cleaned and feeding changed, 
showed an entire cessation of the colicky symptoms. 
When commencing this treatment, the child having pre- 
viously fed on cows' milk, I ordered all milk to be stopped, 
and fed the child on barley-water and rice-water for three 
days, after which I gave Gaertner milk, 1 ounce every 
three hours on the first day, 2 ounces every three hours 
on the second day, 3 ounces every three hours on the third 



GAEKTXEE .AIOTHEE-MILK. 



9.^^ 



day. Considering the syphilitic condition and the fact 
that it was a premature child, the increase of 3 pounds 
and 7 ounces from August 11th until September 25th, 
during a period of six weeks, speaks for itself. 

In conclusion I desire to thank Dr. George Saxe and 
Dr. McConville, Dr. de Hart, and Dr. Emil Joel for kind 
and yalued assistance. 

CHEMICAL EEPORT, BY HERMAI^ POOLE, F.C.S. 

The chemical examinations were made with the idea 
of working out some connection between the substances 
ingested and those excreted. To this end the milk fed 
was analyzed, and from this the quantity of each con- 
stituent fed to the child daily was determined. The fseces 
were also examined so as to ascertain the quantity of un- 
digested fat and casein voided. The results of both sets 
of analysis are given below, the f^ces examinations being 
tabulated and plotted for the better elucidation of the 
facts. 

The Mill-. — The milk used in feeding the children 
contained the following: Fat, 3.05 per cent.; casein, 2.09 
per cent.; milk-sugar, 6 per cent. Specific gravity, 1.0275. 
Eeaction, faintly alkaline. 

When cold, part of the fat separates out, forming a 
layer on the top of the liquid. On being warmed and 
thoroughly shaken, this is completely emulsified and dis- 
tributed through the fluid. Its appearance is that of a 
good, rich milk; in taste a little sweeter than ordinary 
cows" milk; and it is more liquid and molule. 

Each can contained ^/g of a litre, or 20.3-1 cubic 
inches, weighing nearly 9 ^/^ ounces. Of this there was: 
Fat, 0.289 ounce; casein, 0.198 ounce; milk-sugar. 0.569 
ounce: total, 1.056 ounces. 



224 INFANT-FEEDING. 

Each child consumed from three to four cans of the 
milk per day, and hence used: 0.867 to 1.156 ounces of 
fat; 0.594 to 0.792 onnce of casein; 1.707 to 2.276 ounces 
of milk-sugar. 

The milk was perfectly sterilized, a can remaining 
open for five days without thickening or showing acidity. 
The can analyzed had a shot of solder in it, which was 
perfectly bright, showing no chemical action and conse- 
quently no solution of lead. 

The Fceces. — The chemical examination of the f^ces 
was made with a view of obtaining, as nearly as possible, 
the percentage of undigested fat and casein. To this end 
the nurses were instructed to deliver at the laboratory 
three times a week the napkins used during the previous 
twenty-four hours. They were put into cigar-boxes and 
kept in them until examined, which was on the day of re- 
ceiving them. In some cases they were in very good con- 
dition, but many times they were dry and hard, the de- 
posit adhering so firmly to the cloth that it was almost 
impossible to remove an amount sufficient for analysis and 
have it free from adherent cotton-fibre. This was espe- 
cially the case when cotton flannel was used, as was fre- 
quently done. 

In all cases except No. 1 (Shattuck) the weight of 
the faeces given is below that actually voided; in case No. 
2 as much as 25 per cent, can be added to the amount 
given; with Nos. 3 and 4 at least 50 per cent., and on 
some days the amount obtained for analysis was not one- 
half of that actually voided. 

The amount of moisture was, of course, much influ- 
enced by that of the liquid excretion, which naturally 
varied considerably. Still, to avoid necessity of laborious 
analysis, the hypothesis was adopted that the amount of 



GAERTNEfi x\IOTHER-MlLK. 225 

moisture absorbed from the fseces by the cloth was equal 
to that added by the liquid excretion. In some cases I 
think this was correct; in others it is doubtful, especially 
when the fseces as voided were very thin and the napkin 
had evidently been kept long enough to become dry. This 
was a matter very hard to regulate, and must be accepted 
as found. 

The physical appearance did not vary very much in 
individual cases, except in times of intestinal disturbance. 
After a few days the cloths of Case I would have the 
fseces in a single mass, and of such consistence that over 
90 per cent, of it could be easily removed. While the child 
was suffering from an attack of the diarrhoea, as shown by 
a rise in the curve, of course such a condition could not be 
expected. There was a decided improvement in the color 
in each case, it changing from a dead clayey appearance 
to a more or less decided yellow, with occasionally a green- 
ish tinge. When dry, as was sometimes the case, the color 
was uniformly brown or dark brown. 

In most cases the fseces at first were very thin and 
spread all over the cloth, but with those continued for 
a time this character changed to becoming firmer and 
more collected in one place. Some of the cases were so 
poorly taken care of that no mention need be made of 
the condition, it being hardly possible to obtain a suffi- 
cient quantity for satisfactory examination. 

With one exception the smell was uniformly very 
faint and not of an offensive character. The exception 
is the case of the Bassick child, which was fed with egg- 
albumin in addition to the milk. One of the other cases 
showed a faint skatol odor twice, but in none of the others 
was it noticed, and in this case there was not sufficient 
skatol to admit of separation. On many days the lactic- 



226 INFANT-FEEDING. 

acid odor was not perceptible, although litmus-paper 
showed a faint acidity. 

The reaction was almost uniformly acid, not strong 
at any time, and not measurable except in very few in- 
stances, and in these only to a very small fraction of a 
per cent. (0.005), as determined with decinormal ammonia 
solution. On some days no change in moistened test- 
paper could be observed after fifteen minutes. No de- 
cided alkaline reaction was found except once, and this 
was in a dried sample, the reaction of which may have 
been influenced by the urine present. 

The quantity in the same case did not vary very 
much. When a very large figure is given there was evi- 
dently an accumulation of two days, as was shown by the 
physical character. As mentioned above, in some cases I 
was not able to remove more than half of the total, and, 
of course, the amounts given do not fairly represent the 
quantity. This is true with all cases except Case I, which 
will average within 10 per cent, of the total voided. It 
is impossible to impress the kind of people from whom 
these were obtained with any idea of care in this regard, 
and the cloths brought to me show it. 

Remarks analogous to those made regarding the 
amount of excretion apply as well to the water contained. 
Still, a fair average can be found and will probably be 
near the correct one. In most cases I was obliged to put 
all together, wet and dry, to have sufficient for analysis, 
and this at times caused an abnormal number to appear 
as the water-content. This is notably the case with the 
Bassick child, in which the water-content dropped on one 
day to 20 per cent., the cloths being practically dry. It 
was also noticed, in regard to this one, that in this in- 
stance the ordinary strong smell Avas absent. 



GAERTNBE MOTHER-MILK. 227 

In each ease the quantity of fat and casein decreased 
after the milk was used, and remained at a lower per- 
centage. This does not apply to the Bassick case; and, 
in fact, this case was amenable to no law but that of imi- 
forni filth. AVhenever a temporary sickness occurred the 
percentages would rise, and with the Shattuck child this 
rise also occurred nearly simultaneously with her being 
taken to Staten Island, where, although she was reported 
in good health, the percentages kept higher than when she 
was in the city, and on her return to the city they fell 
again. Still, in none of these cases of rise in percentage 
did it reach that point which was attained at the be- 
ginning of the experiments. Xo notice is taken, in these 
results, of the quantity of fat which exists in the f^ces 
combined with calcium, iron, alumina, etc., as insoluble 
soaps. These have undergone some change in the system, 
and only the undigested or unchanged fats which were 
soluble in ether were determined. 

The methods used for determining the fat and casein 
were those mentioned in my paper read before the Ameri- 
can Chemical Society at Detroit in 1897. The faeces 
were dried at 90° F., then at 110° C, and the ether ex- 
tract taken. This ether extract, containing also choles- 
terin with fat, was saponified with alcoholic potassa and 
the cholesterin taken up with ether. The fat-acid soap 
w^as then decomposed by hydrochloric acid and the fat 
determined. The residue from the ether extraction was 
then treated with water and with alcohol. This residue, 
containing undigested casein and epithelial cells from the 
intestinal tract, was digested with diluted hydrochloric acid 
for ten to twelve hours, and this solution used to determine 
the nitrogen by the Kjeldahl method. Casein was consid- 
ered as being 15 per cent, nitrogen. 



228 ■ INFANT-FEEDING. 

Of course, these methods may be open to objections, 
but 1 know of no better ones, and after trying several 
others decided that they would suit the investigation and. 
its requirements the best, and I actually believe that the 
true state of alfairs has been shown better than it would 
have been by any of the methods previously used. 

The following tables show the results of the exami- 
nation, giving the date of receiving the faeces, the general 
appearance, consistence, reaction, quantity in grammes 
that could be removed from the cloth, and the percentages 
of water, fat, and casein obtained by the methods given 
above. The percentages of cholesterin are not given, al- 
thongh they were, of course, obtained. They did not run 
in a uniform proportion to the fat, being at times very 
much larger than at others. (See pages 230 to 232.) 

Discussion of the Curves. — The curves are made by 
nsing the days of the month as abscissas and the per- 
centages as ordinates. The zero-point at the intersection 
of the axes is then the date of the commencement of the 
experiment on the line of the abscissas and per cent, on 
the line of the ordinates. (See page 233.) 

The Shattuck curves: The curve of the casein per- 
centage runs very even nntil the latter part of July, the 
time when the child was taken out into the country. 
While she was there her health was reported good, ex- 
cept at the middle of August, when she had an attack of 
diarrhoea, which lasted some time. This is plainly shown 
on the curve, both casein- and fat- lines responding to 
the conditions. Why the curves rose about Jnly 29th is 
not explained. The fat-curve made a decided downward 
movement from the beginning, and, except for the fluctu^ 
ations due to intestinal troubles, remained low; in all 
cases it remained lower than it was at its inception. This 



GAEETNER MOTHER-MILK. 229 

curve, like that of the casein, tends upward about July 
29th, and does not return to its former low figures. 

The Friedman curves: With these curves, as with 
the Shattuck ones, the effect of the feeding is shown by 
a downward movement. The two lines run closer together 
than in the Shattuck case, and both respond to the diar- 
rhoea which commenced August 1st and was at its height 
at about the 17th. The fat-curve seemed to respond more 
quickly to changes in the intestinal tract than did that of 
the casein, and at times no change in the casein could be 
determined when a marked one in the fat was evident. 
At other times, however, from some cause, the casein 
showed a change not to be noticed in the fat. 

The curves of the other cases are not plotted, as they 
were soon discontinued, and the data obtained were not 
considered sufficient. 

At the time I experimented with this mother-milk it 
was sold and delivered in tin cans. At. that time I dis- 
tinctly told the manufacturer that milk must be fresh and 
must be delivered daily in bottles. Milk of this descrip- 
tion, in which the proteids are mechanically reduced, 
forms an ideal food, and no doubt some future manufact- 
urer will reap the benefit of milk prepared in this manner 
and freshly sold in carefully-sterilized bottles. Thus, we 
can account for the success attained by Professor Escherich 
as well as by Professor Gaertner and others, as theirs is a 
milk prepared daily, and delivered in bottles. Some in- 
teresting editorials in various medical journals followed 
the publication of my article on Gaertner mother-milk. 
To those who are interested I should advise reading an 
editorial in Pediatrics, January 15, 1898, and also an edi- 
torial in the Atlantic Medical Weekly, January 15, 1898. 
An editorial in the Woman's Medical Journal, January, 



230 



INFANT-FEEDIFG. 



Casein, 
Per Cent. 


CO CD CO c. o> CO oc^ c: 

OOt-iOJi-iOOO 




C5 IC (>) 
C^ O rH 




RS88 

O rH r-i CO 

CO O CsJ O^ 
G^ lO 05 Ol 

(M* C^i oi CO 




0^> oi T^ 
CO CO CO 


CO 


„^^„^^^^ 




Oi CO O 

-t -^ \o 
CO oj c<i 


T-l 


1 
Water, Fat, 
Per Per 
Cent. Cent 


c5f>jaqc^c5Qq^05 

IC "^ CO- O^ ci CO CO (>j 

O O O O O O O' o 
l^ O CO T-H X Oi o o 

COi^t-^t-COCOCOCC 


- 


CO 


55.00 
71.50 
63.20 




51.20 
61.20 
75.00 
70.60 




69.00 
69.26 
63.00 


^ 

CD 




888888^8 


62.50 
42.60 
15.80 








12.70 
29.00 
23.40 


g 

s 


o 
< 


Acid .... 
Acid . . 
Acid . . . 
Acid . 
P'aint acid 
Nearly neutral 
Neutral . . 
Neutral . . . 




Faint acid 
Faint acid . 
Faint acid . . 




Very faint acid 
Neutral . . 
Acid .... 
Neutral . . . 




Neutral 

Very faint acid 

Very faint acid 


> 


a 

o 
o 


.S^^^ S S p s 


1 

p. 


quite dry 
Lumps . . . 
Lumps . 




Three soft, 

one dry . 
Lumpy . 
Soft .... 
Soft ... 




Mixed . . 

Soft .... 
Soft . . . 




1 

K 

< 
< 


Clayey 

Clayey .... 
Yellowish 
Slight yellowish 
Yellowish . . 
Yellow . . . . T 
Yellow . . 
Yellow . . . 
Yellow . . 


Yellow , . . 
Yellow brown . . 
Three yellow, one 


brown 

Yellowish . . . 
Yellow green . 
Yellow ... 
Yellow green and 


dark ... 
Yellow . . 
Yellow green 




i 

i < 


June 28th . 
Tune 30th 
Tuly 3d 
July 6th . . 
JulV 8th 
JulV loth . 
July 12th . 
•Fuly 14th . 
July 16th , 


July 18th . 
July 20th . 
July 23d . . 


July 30th . 
August 6th , 
August 13th 
August 23d 


rP -P 

Oi o> 

^^ 

p p 





GAERTNER MOTHER-MILK. 



231 



ll 




































CM 


CO 


10 




CO 




QC 


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05 


CO 




04 


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04 




r-; 







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oi 




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0. 




































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CJD 


bJD 


bD 





232 



INFANT-FEEDING. 





5g 










■<* O O CO 


OS 


t- 




.^S 


lO IC O U5 


t- 


(M 






cc''^ CO (ri 


c4 


CO 




o« 










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00 ooo o 


CO 


■^ 




^«^ 


C^ t- Tj^ O 


c^ 


rH 




^^s 


•^ T^ CO '^ 


'^ 


rfi 




Water, 
Per 

Cent. 


C CO lO o 


00 


CO 




Tf LO "^ Ut) 


t-; 


^ 




00 o i6 »d 


IC 


J^ 




J>(M i> lO 


lO 


lO 




M 










4 f^ 










5>:g 


CO o o o 


CO 


t- 






00 '^ CO lO 


CO 


GO 


w 


T)^ lO lO t-^ 


o 


lO 


2 











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' 






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< 

W 


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M 

g 


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reaction 
nt acid 

nt acid 


1 


> 












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<11ZiFtH fin 


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1—5 


o ■ • o ■ o 






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sl«.ar1 1 




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or exam 
How br 

own . . 
llow an 
llow an 

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< 


t>s >j ^^ iJD bi) 








Q 









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♦ 


5g 


C^ i- CO 


w5 


CD 


"« 


Tj^ Tj< CO 


OH 




fl- 




. 


CO 10 CO 


5h£ 


'^ CO 

r-; ci 06 


(M 04 1-^ 




IC ic 


OJ ic 


CO CO 10 


10 ^ 10 


SB 




P^ 




^>^'g 


10 IC LO 


^^^ 


r- 05 c^ 


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C^D^ 











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p a G 





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m VI m 






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^^5 



GAERTNEE MOTHEK-MILK. 



233 



- Ml" r" 


I 






ZT "r 


1 ^ 


JU -^ -i- 


tH X ^ 




i • ' \ i' 


± ji_tr ..1 r 


ii^ _l"is L 


t i"^==" L 


V u :;<=: ^ 


4 V < it 






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T± tX- 


4 ^ Xx- 


l 4 ' 


^^ ^ ^- 


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iti I 


tx '1 


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1 l~ 


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i J Hi 


UJ 1 H r 




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p ii ' 


Irji tt: 


TX " - 


it tit "■ ' 


i x: 




"■ ■ '" ■ / 1 


f 1 


/ 1 


:t ■ ^it 


t -1-^ -it 


it X it 


t X XX 


-) '^ 


7 7 fit 




/ ii \ 1 


/ 1 \ ' 


^ it H 


X xti i 


/ ! 


it XI 


it xt 


/ i 


^ "'d 


X ^ "^ 


/ ' ! 


, /^ 1 ■; 



5 i> i? ?? S S Jf 5 S ¥ S- *J ij 



234: INFANT-FEEDING. 

1898, published in Toledo, Ohio, is Avorth repeating. 
Here is the article as published:— 

"There has been no greater advance in preventive measures 
than in the reahn of infant-feeding. Where substitution of pabulum 
other. than mothers" milk is necessary, we have for ages been at our 
wits' end for a desirable food. 

"In our research we have tried all sorts of grains and foods 
— and cows" milk has been incorporated in them, with small suc- 
cess. We all are only too familiar with the poor results that accrue 
from cows' milk, and the sequels© that present themselves after a 
diet of this substance. But finally practical measures are instituted 
and tangible results ensue. 

"We are all more or less familiar with the proper method 
of preparing milk, but w^e are sorry to say that the average mother 
is appalled at the machinery which is essential to the proper prep- 
aration of baby's food. 

"In the larger cities this may be secured correctly prepared, 
but in the country and village the lack of proper machinery is an 
insurmountable obstacle that confronts us. 

"It must be admitted that much has been done, and steril- 
izers that are simple produced; but to prepare milk according to 
the latest chemical research is beyond the paraphernalia of the 
average practitioner. 

""What we need is a simple, handy method of eliminating the 
casein from cows' milk, and the man or woman Avho produces it 
will be a benefactor to the race. 

"Louis Fischer, Professor of Diseases of Children in the New 
York School of Clinical Medicine, has made some very satisfactory 
and encouraging tests Avith milk prepared by Gaertner's method, 
and the results are good; so there is no doubt about the value of 
Gaertner's method ; but hoAv is the doctor in the country to pre- 
pare such a milk? 

"The milk used by Dr. Fischer was as follows: — 

"Fat, 3.05 per cent. ; casein, 2.09 per cent. ; milk-sugar, 6 per 
cent. Specific gravity, 1.0275. Reaction, faintly alkaline. 

"When cold, part of the fat separates out, forming a layer on 
the top of the liquid. On being warmed and thoroughly shaken, 
this is completely emulsified and distributed through the fluid. 



BACKHAUS'S MILK. 235 

Its appearance is that of a good, rich milk; it tastes a little 
sweeter than ordinary co^ys' milk; and it is more liquid and mobile. 
"Each can contained ^/g of a litre, or 20.34 cubic inches, weigh- 
ing nearly 9 V2 ounces. Of this, there was: Fat, 0.289 ounce; 
casein, 0.198 ounce; milk-sugar, 0.569 ounce. Total, 1.056 ounces." 

Backhaus's Milk.-^^ 

The following metliod is employed in the production 
of this food. The milk from different breeds of cows is 
mixed and passed through a centrifuge, to separate the 
cream from the milk and to remoye any impurities that 
might have gained access to the milk, notwithstanding 
the great care used in handling. Three grades are j)to- 
duced: two for infants, the third representing full milk in 
its composition. After separating it from the cream the 
milk is exposed to the action of a mixture of rennet, 
trypsin, and sodium carbonate, which are combined in 
such proportions that the trypsin will have converted at 
the end of thirty minutes 30 per cent, of the casein into 
soluble albumin. By this time the action of the rennet 
coagulates the balance of the casein and thus arrests the 
action of the trypsin. The temperature of the mixture 
is now raised to 80° C. (176° F.) by the introduction of 
steam into it. At this temperature it is kept for five 
minutes. At the end of this time it is strained through 
cloths and mixed with half its volume of water, one-fourth 
its volume of cream, and the necessary amount of sugar 
of milk. It is finally put up in bottles holding 125 
grammes (about 4 ounces) and sterilized. 

The second grade, for older children, is obtained by 
mixing equal parts of milk and water with half the quan- 



Archiv filr Kinderheilkunde, B. 26, H. 5 and 6. 



236 INFANT-FEEDING. 

tity of cream and with milk-sugar. This is put up in 
quantities of 200 grammes (about 6 ^/ ^ ounces). 

The third grade, in bottles holding 300 grammes 
(about 10 ounces), represents cows^ milk in composition, 
modified by the above-mentioned process. The composi- 
tion of the three grades is given as follows: — 

Fat 3.1 3.2 3.3 

Sugar of milk 6.0 5.4 4.8 

Casein 0.6 1.8 3.0 

Albumin 1.0 0.3 0.5 

Ash 0.4 0.4 0.7 

The milk has been tried at the Wiener allgemeine 
Poliklinik by Friihwald in a series of twenty cases, the 
histories of which are given by the author. With the ex- 
ception of six, these children have been under observation 
for more than two months. When first seen the children 
were all suffering from different forms of digestive dis- 
turbances, and from malnutrition; some were suffering 
from severe marasmus, and most of them passed through 
some other disease while they were under observation. 
Three of the infants took the breast in addition to the 
Backhaus milk for periods of two and three weeks, when 
they, too, had to be put on the artificial milk entirely. 
The children took about six bottles of No. 1 up to four 
weeks, seven to eight to the end of the second month. 
From the middle of the third month the second degree 
was gradually substituted, while No. 3 was used only in 
the case of an older child. A daily gain was observed of 
from 18 to 30 grammes (about '^/ ^ to 1 ounce). In private 
practice and in healthy children a gain of 50 grammes 
(about 1 ^/^ ounces) not rarely happens. The milk keeps 
well. 



lahmann's vegetable-milk. 337 

Lahmann"s Yegetable-milk. 

Ill Europe^ and recently also in onr country, the feed- 
ing of infants has been enriched with a new product; thus, 
Dr. Lahniann believes that the great panacea is feeding 
infants with milk which he designates as "vegetable- 
milk.^^ It resembles a thick jelly, and is made by Hewwel 
&: Yeithen, Cologne. His theory consists, in brief, in sub- 
stituting nuts and almonds, which are rich in albu- 
min and fat, instead of cereals to dilute milk, his idea 
being that an emulsion, which is digestible and supposed 
to be rich in albumin, is donbtless better than pure water 
or a thin starch-paste. In order to add food-salts, which 
are not supplied by this means, he extracted them from 
leaf vegetables, which are rich in food-salts, and added 
some sugar-syrup. In this manner he believes to have 
made a preparation which he states is, chemically, equal 
to himian milk, -and full of nutritive value. His idea is 
that the interposition of plant-albumin (conglutin) par- 
ticles, which coagulate with difficulty between the coagu- 
lating casein masses, would increase their digestibility by 
breaking them up, and that the digestion of the plant- 
albumin and oil, as well as of the sugar and food-salts, 
would present no difficulty. 

Stutzer, of the University of Bonn, reports thus: The 
vegetable milk is distinguished from children's food by 
the absence of starchy substances. In common with 
Biedert's cream-mixture, the vegetable-milk contains con- 
siderable (Quantities of fat in an emulsified condition. It 
differs from the cream-mixture in the way it is prepared, 
and in its other qualities. 



238 . INFANT-FEEDING. 

Chemical Analysis. 

Fat 34.72 per cent. 

Plant-casein and similar nitrogenous con- 
stituents 12.00 per cent. 

Sugar and plant-dextrin 31.02 per cent. 

Salts 1,64 per cent. 

Water 20.62 per cent. 

My own personal experience has been rather favor- 
able with the use of the vegetable-milk^ inasmuch as an 
emulsion of almonds and nuts was used to dilute the curd 
of cows' milk. Thus^ equal parts of vegetable-milk with 
cows' milk were taken by an infant for several months, 
and it was very well assimilated. Not only did the child 
gain in weight, but the bowels were in a fair condition, 
and the infant remained strong. My experience, however, 
is too limited as yet to give a positive opinion. 

Condensed Milk or Condensed Ceeam. 

Hundreds of infants are fed with condensed' milk. 
This has its reason: — 

First: The readiness with which condensed milk is 
obtained. 

Second: The great cheapness of this article. 

Third: The ease with which the feeding-mixture can 
be prepared. 

Jacobi says that some manufacturers use pure cows' 
milk; others find it in accordance with the health of their 
bank-accounts to use skimmed milk. 

Quantity of Sugar in Condensed Milk. — Mi?k sold in 
our city for immediate use contains about 1.2 to 15 per 
cent, of sugar. Milk to be kept for an indefinite length 
contains as much as 50 per cent, of sugar. These varia- 
tions show how serious it is to use the same quantity of con- 



CONDENSED MILK OR CONDENSED CREAM. 239 

densecl milk all the time and from different sources with 
such an enormous variation in the quantity of sugar. 

Kehrer — quoted by Jacobi — states, regarding it, that 
it increases the formation of lactic acid. Fleischman 
states that it gives rise to thrush and diarrhcea; Daly, 
that it fattens them (?), but gives rise to rachitis. 

The worst specimens of rachitis and spinal rickets 
are seen in my clinic in condensed-milk babies. xVnd still 
in discussing my paper on infant-feeding (read by invita- 
tion before the Society for Medical Progress, April 11. 
1896), and which was published in extenso in Pediatrics for 
July 15, 1896, we find Dessau, with a large infants' ex- 
perience, still advocating the constant use of condensed milk 
as an infant-food. 

In traveling, when good fresh cows' milk cannot be 
obtained, then I permit the use of condensed milk, but for 
a few days or for a week only, as on the ocean steamer, 
Avhere cows' milk cannot be had. 

My experience among hundreds of children seen in 
my Children's Service at the Grerman Poliklinik and also 
at the service at the West-Side German Dispensary during 
these last ten years has been that children so fed have 
rickets; that they are predisposed to the infectious dis- 
orders; that they have less resistance and far less vitality, 
especially in combating such diseases as pneumonia or 
diphtheria; that they have tendencies to hernias and de- 
formities, owing to the softer condition of their muscles 
and bones; that they invariably suffer with constipation, 
alternating with diarrhcea; that their dentition is delayed, 
compared with other methods of hand-feeding. Thus 
summing it up, I cannot approve of this method at all. 

So condensed cream will be lauded by the mother 
whose baby is well, and again the same food will be con- 



240 INFANT-EEEDING. 

(lemned by the mother of an infant whose rickety head, 
bones, and muscles are founded on an impoverished diet 
of condensed milk. We can account for the rickety child, 
but we cannot account for the healthy one on the same 
food. 

Buttermilk. 

Ballot recommends buttermilk as an infant-food. He 
cooks a tablespoonful with a tablespoonful of wheat-flour 
for a few minutes and adds 15 grains of sugar to the same. 

In cases of diarrhoea he substitutes rice-flour instead 
of wheat. 

Buttermilk is composed of: — 

Water 90.62 

Fat . 1.25 

Milk-sugar 3.38 

Nitrogenous substances 3.78 

Lactic acid 0.32 

Salts : 0.50 

Buttermilk contains lactic acid. If allowed to rise 
spontaneously so that it can be ^^skimmed" off, we have, 
even in low temperatures, several acids formed, believed 
to be laetic acid and fatty acids. 

When milk is skimmed it has a specific gravity of 
1.035 to 1.037 and contains: — 

Water 90.63 

Nitrogenous substances 3.06 

Fat 0.97 

Milk-sugar 4.77 

Salts ; 0.75 

The author has seen decided benefit from skimmed 
milk, and from the above chemical composition it can be 
readily seen that it contains some nutritive properties. 



COCOA. 241 

It is naturally unsuited to the requirements of an infant; 
in fact^ it is, as Jacobi puts it, very decidedly "objection- 
able/^ 

It is more adapted for a child after the period of 
weaning. 

Cocoa. 

Dr. H. Cohn/* in describing the chemical value of 
cocoa as nourishment, states his belief that it is overrated, 
and denies the value of the same. He bases his statement 
in the poor method of assimilation, owing to the large 
quantity of fat contained therein, which could be removed 
by chemical process. Cocoa also contains 5.5 per cent, 
of tannic acid. Besides, the albuminoids are converted, 
by the process of roasting, into a very indigestible product. 
About the tannic acid, he says that it precipitates the 
digestive ferments, and unites with the albuminoids into 
insoluble compounds, causing the constipating factor. 
According to his experiments, only one-half of the 16.6 
per cent, of the albuminoids are absorbed, and, in order 
to give the human body enough cocoa to have a sufficient 
quantity of proteids, it would be necessary to feed at least 
somewhat over 2 pounds daily, provided cocoa alone was 
given for nourishment. 



^* Zeitschrift fiir physiologisclie Chemie, xx, 1, 2. 

16 



CHAPTEE XXXI. 

The Feeding of Diphtheria-Intubation Cases. 

When an infant has a foreign body — the intubation- 
tube — in its throat, swallowing is more difficult, because 
the epiglottis cannot entirely close. Frequently, while 
swallowing there is coughing, gagging, and regurgita- 
tion, caused by fluids (food) trickling into the trachea. 
In this manner, it is claimed, Schluck-pneumonia has fre- 
quently been caused. If the child^s head is turned to one 
side — either side — and swallowing is provoked in this 
manner, then we can sometimes avoid this trickling into 
the trachea; or another method is to lay the child fiat on 
its back and allow the head to hang lower than its body, 
and feed it slowly with a spoon. This is really known as 
the Casselberry method of diphtheritic feeding. 

If this method is not satisfactory, and if we find that 
we cannot get enough food into our patient, then we can 
resort to rectal feeding. 

RECTAL FEEDING IN DIPHTHERIA. 

Bear in mind that the rectum absorbs, and does not 
digest. Hence, all food must be peptonized. The method 
is very simple. First: Always cleanse the rectum. This 
is done by washing the rectum with an enema of a pint 
of soap-water made by dissolving ordinary Castile soap 
or glycerin soap in warm water. The temperature of the 
soap-water to be 100° to 110° F. Quantity, from 1 to 2 
pints. After the rectum is cleaned, and the faecal move- 
ments all passed, it is advisable to wait about five minutes 

(242) 



FEEDING OF DIPHTHERIA-INTUBATION" CASES. 243 

to give the rectum a chance to rest. Then we proceed to 
inject the rectum with a suitable quantity of peptonized 
egg. Small quantities are better borne than large quanti- 
ties; hence^ no more than 1 to 2 ounces should be thrown 
in at one time. 

The following formula will give an idea of the way 
in which food is to be prepared for rectal injection: — 

Take 2 teaspoonfuls of ordinary starch and rub the 
same up with an ounce of lukewarm water. This makes 
a very milky mixture. To this mixture we add the yolk 
of 1 egg, and one-half of an ordinary Fairchild peptoniz- 
ing tube. This is to be slowly, but forcibly, injected into 
the rectum. Various methods of injecting can be used, 
the simplest being with the aid of a bulb rectal syringe, 
known as the infant's rectal syringe. (See Fig. 50.) 

Another method consists in pouring this emulsion of 
starch-water and peptonized egg into a funnel ending in 
a rectal tube, a so-called rectal feeding-tube made by Tie- 
mann, of New York City. (See Fig. 52.) 

The secret of success is undoubtedly the amount of 
food brought into a child's body during its illness, and, 
the more food absorbed, the greater resistance will the 
child have. It is advisable not to overtax the rectum; 
hence, my method of feeding is to use the peptonized yolk 
of egg with starch-water as mentioned above, and follow 
it — three hours later — by substituting an ounce of pep- 
tonized milk instead of the yolk of egg. 

With this ounce of milk an ounce of starch-water 
should be combined. If there is looseness of the bowels, 
and the food will not remain in the rectum, then 1 or 2 
drops of the ordinary tincture of opium added to each 
enema will soon quiet the irritation of the rectum, and 
thus aid in retainino- the nutrient enema. 



CHAPTER XXXII. 



Forced Feeding. 



This is commonly known as gavage. This consists in 
forcing a small feeding-tube, a No. 7 rubber catheter, 
through the mouth and pushing it forcibly toward the 
pharynx and directly into the stomach. This feeding- 
tube consists of a black hard-rubber or glass funnel to 
which is attached a piece of rubber tubing about ten 
inches long; then a small glass tube (a connecting tube) 
over which is drawn the rubber No. 7 catheter. In case of 
emergency, nothing is handier as a connector than the 
glass portion of the ordinary medicine-dropper, the 
smaller end will serve to connect with the rubber catheter 
mentioned above, and over the larger portion of the medi- 
cine-dropper we draw the rubber tubing connected with 
the funnel. This little apparatus has been very neatly 
combined for the author's use by Messrs. G-eorge Tiemann 
& Co. (See Fig. 52.) 

Having pushed this small catheter into the stomach, 
we pour the food, usually several ounces of peptonized 
milk, or dextrinized barley and milk, or albumin-water, or 
the white of a raw egg mixed with half of a teacup of cof- 
fee and milk, or, if desired, a good concentrated soup, or 
bouillon, or broth, can be used. The same interval govern- 
ing ordinary meals should be more strictly adhered to while 
this process of feeding is used. It is self -understood that 
all instruments, utensils, and food must be strictly clean 
and sterile. 

Place the child flat on its back, and, first, pin either 
a heavy blanket or a stout sheet securely behind the body 

(244) 



FOECED FEEDING. 245 

SO that the hands are pinned down; have the assistant 
hold the child's elbows securely on each side; then force 
the mouth open and quickly pass the catheter, pour the 
food into the funnel, and when the funnel is empty with- 
draw^ the catheter as quickly as possible. If this forced 
feeding is done very slowly or clumsily, then nausea and 
sometimes vomiting will be produced thereby. Hence, 
the technique should be carried out as completely as pos- 
sible. 

NASAL FEEDING. 

In some instances it is easier to pass a soft, flexible 
catheter through the right or left nostril into the oesopha- 
gus, and forcibly push the same into the stomach. This 
is a very simple process, and I have never yet been able 
to pass the tube into the larynx while gliding it toward 
the oesophagus. All food should be given warm — prefer- 
ably between 98° and 100° F. Small quantities of milk, 
strained gruel, broth, or albumin-water will be far better 
digested than heavier food. In some instances, where 
milk is not well borne, the ordinary unsweetened cream, 
in the proportion of 1 teaspoonful of cream to 3 ounces 
of water, will serve quite well. In other cases I have 
used very successfully several teaspoonfuls of Mellin's 
food diluted with an ounce of raw milk, to which 1 
ounce of boiling water was added. This latter mixture 
is highly nutritious, and scalds the milk, and does not 
require either pasteurization or sterilization. Meat-juice 
and expressed steak-juice or roast-beef juice should not 
be forgotten. 

Ice-cream and water-ices, very grateful to the feverish 
patient, contain some nourishment, and should be given in 
moderation. 



/ 
246 INFANT-FEEDING. 

HAND-FEEDING. 

If children are old enough and can be fed with a 
spoon^ then I invariably prefer semisolid food^ such as 
rice and milk, oatmeal and milk, farina and milk, zwieback 
soaked in milk, cornstarch pudding, tapioca pudding, or 
some custard. Thus, my readers must bear in mind, at 
the risk of repeating, that we cannot make laws governing 
all, but must seek to individualize, and then, following 
the outlines and suggestions given above, adapt the same 
to the requirements of each case. 



CHAPTER XXXIII. 



Modified Milk. 



Ix an article published by the author in Pediatrics, 
July 15, 1896, the following appears: — 

"It is now several years since a Walker-Gordon Milk- 
laboratory was established in ISTew York. The feeding of 
infants is based on mixing the ingredients in such com- 
l)ination that, when combined, they should resemble cer- 
tain chemical forniulge of breast-milk at various ages. 

"Blanks are given the physician, which are filled out 
according to the child's age and weight, calling for a 
definite percentage of fat, milk-sugar, proteids, water; 
and prescribing of feedings, the amount of each feeding, 
the percentage of alkalinity, and the length of time in 
which the mixture is to be sterilized or pasteurized. This 
would be a practical method, and appeals to the physician 
at first, but it is necessary to familiarize one's self with 
the mysteries of this method before one can properly 
judge of its merits. I have given modified milk a careful 
trial in my private practice; it is too expensive for either 
dispensary or hospital cases. '^ 

One of the first symptoms encountered was constipa- 
tion, which could not be relieved; in five children fed ex- 
clusively on modified milk, the constipation was so severe 
that the formula was changed many times: we added more 
cream, and still more cream, until we finally abandoned 
the feeding by this method. 

The following case will illustrate what has been said: 

N. R., a healthy female, was put, soon after birth, on modi- 
fied milk. 

October 14th: Fat, 2.0; milk-sugar, 5.0; albuminoids, 0.75; 
lime-water, Vir- Eight feedings: 2 ounces in each. 

(247) 



348 INPANT-FEEDING. 

October 17th: Constipation. Fat, 2.5; milk-sugar, 6.0; albu- 
min, 1.0; lime-water, ^/m- Nine feedings; 2 V2 ounces in each. 

October 27th: Fat, 3.0; milk-sugar, 6.0; albuminoids, 1.0; 
lime-water, ^/m; barley-jelly, Vis- Ten feedings; 3 ounces in each. 

November 5th: Fat, 3.5; milk-sugar, 6.0; albuminoids, 1.0; 
lime-water, ^/le; barley-jelly, Vi5- Ten feedings; 3 ounces in each. 

November 17th: Fat, 4.0; milk-sugar, 6.0; albuminoids, 1.5; 
lime-water, V20; nO' barley. Ten feedings; 3 ounces in each. 

November 19th: Curded stools, dyspeptic diarrhoea. Fat, 4.0; 
milk-sugar, 6.5; albuminoids, 1.0; lime-water, ^/zq. Ten feedings; 
3 ounces in each. 

The child did not increase in weight, had a rectal temperature 
of 100°, slightly-furred tongue, vomited curds, had greenish stools 
containing undigested particles of fat and true casein and large 
masses of mucus. The diagnosis of dyspepsia infantum was made; 
hand-feeding was stopped, the child's alimentary tract was cleaned 
by giving cascara sagrada, and a proper wet-nurse was secured. 
The infant at this time was about 6 weeks old. The child nursed 
very well, and after a few days the stools were normal, both in 
consistency and color. The infant gained steadily from 4 to 6 and 
sometimes 8 ounces per week, until she was 7 months old, when 
suddenly the weight remained stationary. The child was bright 
. and cheerful, but I deemed it necessary to have the milk of the 
wet-nurse examined by a competent chemist; a specimen of the 
same was secured in the usual manner described by me in a pre- 
vious section on "Method of Obtaining Breast-milk for Chemical 
Examinations." This specimen was examined for the author by 
John S. Adriance, the chemist of the Nursery and Child's Hospital, 
who reported the following: — 

Fat 2.000 per cent. 

Sugar 7.431 per cent. 

Proteids 0.882 per cent. 

Ash 0.162 per cent. 

Total solids 10.475 per cent. 

Water 89.525 per cent. 

Specific gravity at 70° F 1.0316 

Reaction alkaline. 



MODIFIED MILK. 249 

In the chemical result above given it is very evident that a 
deficiency in the proteids exists; hence it accounted, not only for 
the stationary weight, but for the late dentition. The child did 
not gain an ounce in one month. We discharged the wet-nurse. 
The following food was ordered: — 

Milk 3 ounces. 

Cream 2 teaspoonfuls. 

Oatmeal-jelly 3 ounces. 

Lime-water 1 drachm. 

Milk-sugar 1 teaspoonful. 

Salt 1 pinch. 

Sterilize the above and feed every three hours, the above 
quantity being for one feeding. 

After the infant had taken this food for 6 days it was cheer- 
ful, had had one and two yellow stools daily, and gained 6 ounces 
in 6 days. 

The above case will illustrate: — 

1. That the child was decidedly dyspeptic while taking its 
modified milk for about 6 weeks. 

2. That for about 6 months the infant thrived very well on 
the milk of a wet-nurse, 

3. That the stationary weight of the infant and the chemical 
examination of the milk of the wet-nurse showed deficient pro- 
teids, which accounted for this non-increase in weight and the late- 
ness in dentition. 

4. That a proper milk-mixture, which agreed vei:y well, suited 
the requirement of this infant^ and emphasizes the fact that we 
must individualize in each and every case. 

It is impossible to make an emulsion like milk from 
its component parts by a synthetic process. Let it there- 
fore be distinctly understood that^ once a milk-emulsion 
is broken np^ as is done in centrifuging milk and removing 
the cream^ mixing the whole will never restore the uni- 
formity of the emulsion that existed prior to this division. 

Time and again have I examined a drop of milk under 
the microscope and found an unevenly-divided emulsion 



250 INFANT-FEEDING. 

of modified milk^ resembling eolostrum-mill^. The macro- 
scopical examination of modified milk will always show a 
large amonnt of butter-fat swimming on top of each bottle 
of milk when it is cool. If this fat is part of the formula 
prescribed^ then the modified milk does not contain its 
original amount of fat^ and much more must be pre- 
scribedj to allow for the separation of the same. Hence 
it would seem that the percentage portion of the food 
must necessarily be incorrect. 

I am in accord with Jacobi/^ who says, speaking of 
laboratory-fed babies: — 

"Only one observation struck me in many cases: the 
formation of the muscles and particularly of the bones 
appeared to be slow. The teeth came a number of weeks 
or even months too late; the cranial bones turned 
slightly soft in not a few instances; in many such cases 
I had to add animal broths or juice before the usual time. 
In two, when I tried phosphorus (elixir phosphori), it was 
rejected; in all others it was well borne and useful.^' 

Jacobi further states, in speaking of the difference 
between Walker-Gordon and Gaertner mother-milk, that 
the latter is patented, the former is not. It is a well- 
known fact that Walker-Gordon milk is patented. 

Dr. A. Worcester,^*' speaking of the modified-milk 
question, calls attention to the lately-patented Walker- 
Gordon process; so also has Dr. Baner,-^" of 'New York, 
and many others. In the Indian Lancet, editorially. 
May 1, 1898, we read the following: "We confess that we 



55 "Therapeutics of Infancy and Childhood," page 38, second 
edition. 

''"Boston Medical and Surgical Journal, September 19, 1895. 
'' Xew York Medical Journal. 



I 



MODIFIED MILK. 251 

cannot agree with the writer of a paper, Dr. D. J. Evans, 
of the Montreal Foundling Hospital, in what appears to 
ns to be his wholesale distrust of the provision made by 
E"atnre for the needs of infancy. We cannot but think 
that his process errs by overelaboration of those simpler 
measures by which, with some judicious help in times of 
difficulty, she has, on the whole, very successfully reared 
the race of man through countless generations." 

In a paper published by Rotch^'^ we find the following: 
"I would plead in the name of common humanity, as 
well as in that of the intelligence and scientific reputa- 
tion of our profession, that this representative body of 
American physicians should, in its endeavor to advance 
the general subject of infant-feeding, record itself as op- 
posed to the use of patent or proprietary food of every 
description." 

Further on, in the same paper, the writer states: — 
"We should, in fact, remember that the nutriment 
which we are endeavoring to copy, far- from being a cheap 
product, is, on the contrary, a very expensive one." I 
leave it to my readers to judge of the sincerity of the 
writer. 

Dr. Louis Starr^^ gives a critical review of his clinical 
study with laboratory-milk for the last few years. He 
states: — 

"With all the above advantages, laboratory-milk is 
theoretically the most perfect substitute for normal 
human milk that science has yet devised. But unfortu- 
nately clinical experience, in my own practice at least, 
does not bear this theorv out. 



^^ Boston Medical and Surgical Journal, November 23, 1893. 
'^Archives of Pediatrics, Januarv, 1900. 



252 INFANT-FEEDING. 

"The following is a generalization of the results of 
over two 3''ears' study of the use of laboratory milk-food in 
substitute feeding: — 

"These results may be classified under three heads, 
viz.: — 

"(a) The satisfactory, — embracing the very excep- 
tional cases of perfectly-healthy children who have been 
continuously fed upon laboratory-milk, from, or shortly 
after, birth up to the time of beginning a mixed diet. I 
have seen but three of these in as many years. 

"(&) The partially satisfactory, — including cases, 
much greater in number than the preceding class, in 
which laboratory-milk was used for a considerable period 
— six months to a year — without producing active illness, 
but gradually inducing health conditions necessitating a 
change of food. Of this class I have seen sixteen cases. 

"(c) The unsatisfactory. The instances of this group 
are by far the most numerous, and in it, in my experience, 
may be placed the vast majority of infants fed upon 
laboratory-milk after the first eight weeks of life. It em- 
braces those cases in which laboratory-milk feeding must, 
of necessity, be discontinued on account of the onset of 
some acute disorder of undoubted dietetic origin. My 
cases in this class number thirty-five. 

"The unhealthy conditions referred to in the second 
class present a very uniform group of symptoms, viz.: 
pallid, dry skin; dry, lustreless hair; flabby, soft muscles; 
indifferent appetite; inactive — not decidedly constipated 
— bowels, with clay-colored evacuations; light-colored 
urine; listlessness and disinclination to play; peevishness 
and restless sleep — in a word, the features of malnutrition. 
With the muscle-flabbiness there is not always emaciation, 
but the two conditions are often associated and the little 



MODIFIED MILK. 253 

sufferer is both weak and puny, and the observant mother 
states: ^I do not know what is the matter with my child; 
he is not ill, but he does not seem to thrive and is not 
like other healthy babies/ 

^'Illustrative Case. — Boy, aged 10 months, presented above 
symptoms; no history of acute illness. Fed from birth upon 
laboratory-milk, modified in composition as age advanced, until 
the following strength was reached: — 

Fat 4.00 No. of feedings. .5. 

Sugar 0.00 Quantity 8 ounces. 

Albuminoids 2.50 Alkalinity 5 per cent. 

Heat 167° F. 

"Improvement began soon and continued steadily under a 
domestic mixture of: — 

Calculated Percentage. 

Cream, 16 per cent 1 tablespoonful. Fat 3.75 

Milk 11 tablespoonfuls. Proteids 2.97 

Milk-sugar 1 teaspoonful. Sugar 4.94 

Water 4 tablespoonfvils. 

"For each feeding, every three hours, five meals daily. 

"The acute disorders occurring in the third class are: 

^'Fh'st. — Acute g astro-intestinal catarrh, indicated by 

pyrexia, vomiting, and diarrhoea with the expulsion of 

curds and greenish mucus or large quantities of greenish 

serum. 

"Illustrative Case. — Girl, aged 2 ^/o months when seen in con- 
sultation. She had been fed from birth on laboratory-milk: — 

First and Second Weeks. 

Fat 2.00 Alkalinity 5 per cent. 

Sugar 5.00 Heat 167" F. 

Albuminoids 0.75 

"Bowels occasionally disturbed, stools curdled and greenish. 
No gain in weight. 



254 INFANT-FEEDING. 

Third to Sixth Week. 

Fat 4.00 Alkalinity 5 per cent. 

Sugar 6.00 Heat 167° F. 

Albuminoids 1.00 

"Bowel movements never quite normal, always too frequent 
and greenish, and often very green, with isolated hard curds and a 
quantity of mucus; infant restless, sleeps badly, colicky, and gain- 
ing weight very slowly. 

Sixth to Eighth Week. 

Fat 4.00 Alkalinity 5 per cent. 

Sugar 6.00 Heat 167° F. 

Albuminoids 0.75 

"No change in intestinal symptoms; no gain in weight; infant 
growing feeble. 

Ninth Week. 
"Same food, predigested six minutes Avith Fairchild's pepto- 
genic milk-powder. 

"No improvement, except that curds passed are smaller and 
softer. (Predigestion performed at laboratory?) 

"In the tenth week the infant suddenly became very ill ; high 
fever; vomiting; frequent, large, green, watery evacuations, with 
mucus and curds; rapid and extreme prostration. Milk-food was 
stopped for twenty-four hours. Fed on barley-water and raw beef- 
juice. Intestines disinfected with small doses of calomel, and 
cleansed by high rectal injections of normal saline solution. 

"On succeeding day fed upon: — 

Calculated Percentage. 

Cream, 16 per cent 1 tablespoonful. Fat 2.67 

Milk 2 tablespoonful s. Albuminoids . . .1.29 

Milk-sugar 1 teaspoonful. Sugar 4.24 

Salt 1 pinch. 

Water 6 tablespoonfuls. 

"For each feeding, every 2 ^/o hours. 

"This was gradually increased in strength as the improve- 
ment, which was continuous, allowed, until at the end of a week 
the following was being taken: — 



IIODIFIED MILK. 255 

Calculated Percentage. 

Cream^ 16 per cent 1 tablespoonful. Fat 3.55 

Milk 4 tablespoonfuls. Albuminoids . . .2.18 

Milk-sugar 1 teaspoonful. Sugar 5.24 

Salt 1 pinch. 

Water 4 tablespoonfuls. 

"For each feeding, every 2 V2 hours. 

"There was no further trouble after the above domestic mixt- 
ures were employed; the evacuations became normal, and strength 
and weight improved rapidly, the food being increased in strength 
and quantity as increasing age demanded. 

"Second. Infantile S curvy .—Tliia condition is an ex- 
ceptional result of laboratory-feeding, but the possibility 
of its occurrence is of importance. 

"The following notes were kindly furnished by Dr. 
W. F. Teller, in whose practice the case occurred: — 

"Boy, born January 28, 1897 ; weight seven pounds. It being 
impossible for the mother to feed the child from the breast, he was 
placed upon laboratory-milk in the following proportions: — 

Fat 1.00 

Sugar 5.00 

Proteids 0.75 

"This was gradually increased in strength until by the middle 
of April (aged 2 ^/o months) he was taking: — 

Fat 4.00 

Sugar 7.00 

Proteids 1.50 

"Intestinal disturbance with green, mucoid evacuations con- 
taining curds ensuing, the food was changed to: — 

Fat 3.50 

Sugar 6.50 

Proteids 1.50 

"Eight feedings of 4 V2 ounces each. 



256 INFANT-FEEDING. 

"On June 15th (aged 5 V2 months) the weight was twelve 
pounds. The intestinal indigestion continuing, a further change 
was made: — 

Fat 3.50 

Sugar 6.50 

Proteids 1.00 

"Seven feedings of 5 ounces each. 

"About one week later the child began to evince pain on mov- 
ing or handling the legs, which were drawn up toward the abdomen 
and rigid; there were no fusiform swellings, and no petechial spots. 
Four incisor teeth were cut, and the gums about these were purple, 
swollen, spongy, and bleeding. There was diarrhoea, with green, 
curdled, and fermented evacuations; no fever. 

"Orange- juice and raw beef -juice were ordered, with a simple 
treatment directed to the intestinal disturbance, and the scurvy 
symptoms gradually improved and soon disappeared entirely. 

"After this until October (aged 7 months) he had: — 

Fat 3.50 

Sugar 6.00 

Albuminoids 1.00 

"Six feedings of 6 V2 ounces each. Together with half an 
ounce of raw beef- juice once daily, given 'because it was necessary 
to keep the albuminoid percentage so low in the laboratory-milk 
mixture.' 

"In October, as the child, though not ill, did not thrive, the 
beef -juice and laboratory-milk were discontinued, and a home- 
modified milk-food substituted^, with the most satisfactory results. 



"The question now naturally arises: Why should a 
food capahle of being prescribed to approach so nearly 
breast-milk in chemical composition, so uniform in its 
make-up, so sterile and so easily and accurately varied to 
meet digestive emergencies, fail when put to a clinical 
test? 



MODIFIED MILK. • 257 

"My answer is that in its composition all the fat is 
removed by a separator, and the food as prepared for the 
infant is a recombination of this fat and an alkaline so- 
Intion of the proteids and sugar. In a word, the natural 
emulsion is destroyed. This, I think, in some way lessens 
the digestibility of the proteids and leads to conditions 
either of malnutrition or to an irritative diarrhoea with 
the expulsion of the undigested proteids in the form of 
compact curds — and this, too, despite changes in the pro- 
portion of the proteids; for the partially-starved chil- 
dren are attacked with vomiting or diarrhoea with fever if 
the percentage of proteids be increased (say, to 2.00 per 
cent, at ten months), and those having irritative diarrhoea 
are not benefited until the percentage is cut down to a 
starvation-point (0.75 per cent, in a child of three 
months still showed numerous curds in the evacuations). 
What a contrast to normal breast-milk, an emulsion hav- 
ing over 2 per cent, of proteids (Leeds)! 

"I have never seen an infant from two to ten months 
able to stand a laboratory-mixture of stronger proteid per- 
centage than 1.50, and have often seen cases of two 
months and more unable to digest a percentage of 0.50. 

"On the other hand, how does it stand with the 
cream, milk, sugar of milk, and water mixture made at 
home by capable heads and careful hands? These mixt- 
ures are still modified-milk mixtures; but their basis is 
unseparated milk, a natural emulsion, containing fat, pro- 
teids, sugar, and salts. Under this physical condition the 
proteids are much more easily digested; so that a badly 
nourished child of ten months, in whom laboratory-milk 
percentage cannot be forced higher than 1.50 proteids, 
Avill easily digest and grow strong upon a domestic mixture 
of:— 

IT 



'i5(S INFANT-FEEDING. 

Calcu la ted Percentage. 

Cream, IG per cent 5ss. Fat 3.75 

Milk Svss. Sugar 4.94 

Milk-sugar 3j. Proteids 2.97 

Water Bij. 

'^Ancl an infant of two months having an irritative 
diarrhoea on a starvation-diet of 0.50 per cent, proteids 
will begin to improve and soon grow strong and well on: 

Calculated Percentage. 

Cream, 16 per cent gss. Fat 4.00 

Milk 3x. Sugar 6.22 

Milk-sugar 3j. Proteids 2.09 

Water giss. 

^^In domestic modification^ of course^ the same care 
mnst be taken to secure clean^ pure milk and cream 
from healthy^ well-kept cows. This is quite possible 
now in Philadelphia^ and is becoming easier each year, 
as more attention is being given to infant-feeding and 
greater demand is being made for a pure milk-supply. 
Pasteurization is as readily done in the nursery as in the 
laboratory. Accurate measurement of quantities and 
cleanliness of vessels and feeding-bottles is equally pos- 
sible and, in my experience, quite as certain at home as 
in the shop. 

"The milk and cream from a dairy may vary slightly 
in chemical composition from day to day, but this varia- 
tion seems to me to be a minor detail, and of questionable 
importance when compared with the separator's destruc- 
tion of the physical properties of the basal milk. One 
certainly would not sacrifice everything to chemical ac- 
curacy." 

Clinical experience has demonstrated the fact that 
some children will thrive on condensed milk in spite of 



MODIFIED MILK. 259 

faulty hygiene, while others will not thrive in the best 
environment with the best form of feeding; in other 
words, some children will thrive on modified milk, others 
will not. The majority of the cases seen by the writer 
suffered with intense constipation, having clay-colored 
stools, in one instance, in which two children in one family 
were constantly fed on modified milk of varying propor- 
tions, the formulas were changed at least a half-dozen 
times with the usual increase of fat and sugar and lower- 
ing of the proteids, and in spite of this fact, after re- 
peated trials, and no benefit, this feeding-method was 
abandoned. A child recently seen by the author did not 
gain one ounce in four mmitlis. This was one of the reasons 
that prompted the family to change both the physician 
and the food. The child, about two years old, was very 
pale, restless at night, quite peevish during the day, and 
decidedly backward in development. It could neither 
speak nor walk, although the teeth were well developed. 
From the time the modified milk was discontinued, and a 
nitrogenous diet given, the infant improved, and from 
last reports is quite well developed. 

The records of the laboratory will probably show that, 
at the time the writer first used modified milk, he had at 
least a dozen at one time using the same, but his results 
were identical with those quoted by Dr. Louis Starr, of 
Philadelphia, and hence home-modification of milk has 
been used to the exclusion of laboratory-modification. 

Do not let us blindfold ourselves with the belief that 
an infant is thriving unless our baby shows a regularity 
in the increase of weight, sleeps well at night, for at least 
from six to nine hours continuously, and, above all, as- 
similates its food, as evidenced by regular, unaided move- 
ments of the bowels; such movements should be once or 



260 INFANT-FEEDING. 

twice ill twenty-four liours^ have a yellowish-white color, 
and a nnistard-like consistency. If the stool is hard or 
lumpy or pasty, like putty, then it is certainly abnormal, 
and shows improper food. The same is also true if the 
stool contains white particles of cheesy curds, showing a 
casein indigestion. In one infant, which had taken modi- 
fied milk continuously for seven months, an obstinate con- 
stipation was only relieved after full doses of codliver-oil 
and extract of malt were given for several weeks — aided 
by massage, besides changing the diet. 

PALLOR OF THE SKIN. 

An unusual pallor of the skin, and also of the con- 
junctival mucous membrane, has frequently been noticed 
in modified-milk babies. In one instance an extreme leu- 
cocytosis was noticed for the treatment of which iron was 
given. i\.n examination of a drop of blood showed a 
diminution of the red blood-corpuscles and an excess of 
the white blood-corpuscles. A decided hsemic murmur 
was noticeable in the vessels of the neck, in a child, two 
years old, which had been fed continually on modified 
milk. 

Craniotabes, softening of the cranial bones, as well 
as very late closing of the anterior fontanelle has also 
been -observed in some children fed with this form of food. 
A boy, 4 years old. a typical Walker-Gordon baby, who 
was fed exclusively on modified milk, now shows typical 
knock-knees, besides having been under the treatment of 
his physician for a general furunculosis of the scalp. The 
furuncles were of such size that they required incision 
several times; others opened spontaneously. 

I have previously reported''^ "three distinct cases of 



Pediatrics, July 15, 1896, page 68. 



MODIFIED MILK. 261 

rickets in laboratory-fed babies^ and if we compare the 
ordinary infant that we see brought to our dispensary 
from tenement-houses, chiklren that are fed on condensed 
milk and water, they are much the same class of rickets 
at less expense.'' Thus, I fully agree with Louis Starr, of 
Philadelphia, who, in his paper,^^ says: ''T must not be 
understood as condemning laboratory-milk absolutely; if 
its introduction has done nothing else, it has greatly ad- 
vanced substitute infant-feeding, by fixing the attention of 
the profession upon the importance of cleanliness and ac- 
curacy in the quantity and chemical composition of cows" 
milk foods and by placing the whole question upon a 
higher scientific plane than it has ever reached before.'" 

MATEENA HOME-MODIFIER. 

This is a glass apparatus for the modification of cows' 
milk at home, and consists of a glass vessel with pouring- 
lip, shaped like a graduate, holding sixteen ounces. The 
outer surface is divided by vertical lines into seven panels; 
one panel shows the ordinary ounce graduation; the six 
others show six different formulae, so arranged as to be 
suitable for the entire first yearns feeding. On the follow- 
ing page is a more or less accurate reproduction of the ar- 
rangement of these panels. 

It is possible to obtain other percentages than those 
shown on the panels, by mixing what is called for by two 
adjacent formulae; as, for instance, equal quantities made 
according to Formulse 1 and 2 combined will give: fat, 
2 V^ per cent.; proteids, 0.7 per cent.; sugar, 6 per cent. 

As may readily be seen, all the formulae call for the 



Archives of Pediatrics, page 7, January, 1900. 



262 



INFANT-FEEDING. 



same ingredients^ excepting the sixth, which, instead of 
water, reqnircs barley-gruel, and granulated sugar in place 



of milk-sugar 



1. 




4. 


5 


0. 


3d-14tli Day. 

Fat, 2 5f. 

Proteids, 0.0 '> . 

Sugar, 6 ^i. 


2d-()tli week, (itii-lltli week. 
Fat, 2j.^ ';i . Fat, 8 <■'! . 
Proteids, O.S'f. .^ Proteids, 1 '/o . 
Sugar, Off. Sugar, Off. 


11 wk.-5in(). 

Fat,3J^«J. 

Proteids, 13^ '/L 

Sugar. 7 fc . 


r)th-9th mo. 

Fat. 4 5i. 

Proteids, 2 ft. 

Sugar, 7 fi . 


9tli-12tli 111.). 

Fat. 3^2 fi. 

Proteids, 2K. 'i. . 

Sugar, 31, V. 


1 
Milk Milk 


Milk 


Milk 


Milk 


Milk 


Cieam ' 










i C.'icain 












('re:im 








r.ime-water 










1 Lime-wnter 










Water 


Till lie- water 


Creaui 






Water 














Water 


Lime-water 


Cream 
Linio-vvater 


* 












• 


Water 


Water 


Cream 
Barley-giiiel 


Milk-sugar 


Milk-sugar 


Milk sugar 


Milk-sugar 


i\[ ilk- sugar 

-- - - - X 


Cjr. sugar 

















The method of using the apparatus is extremely 
simple. Having decided upon the formula to be u.sed, 
that panel is to be observed to the exclusion of all the 
others. The respective ingredients are then poured into 
the vessel, to the line below the designated substance. 
Thus, milk-sugar is put in first (or, in its absence, gran- 
ulated; and the line with the cross shows to what point 
the latter should be used), then the water, lime-water. 



MODIFIED MILK. 



263 



cream, and milk in the order shown. 



The whole is then 
stirred, and the result will be a milk whose formula is at 
the top of the panel. The milk used with the apparatus 
should he good average milk. The cream should be the 
light centrifugal cream as obtained in bottled milk (16-20 
per cent.). The water should be hot, to dissolve the sugar. 




Fig. 37. 



The barley-gruel should be prepared in the usual way with 
Robinson's or ordinary barley. 

According to the age and size of the child, the vessel 
must be filled once, twice, or three times to obtain the 
quantity requisite for the twenty-four hours' feeding. 
The pouring into bottles and sterilization are then done 
as usual. Full directions, including a schedule for the 
twenty-four hours' feeding at the various periods of the 



2()4 INFANT-FEEDING. 

child^s growth^ accompany the apparatus^ which is simple, 
accurate, and economical, making properly-modified milk 
of practical value obtainable in places where it has 
hitherto been impossible to get it. 

The materna is adapted for home use only when the 
physician notes results. To intrust an apparatus of this 
kind into the hands of a mother or nurse not conversant 
with the difference in the percentage of fat contained in 
cream is not only wrong, but will prove disastrous to the 
infant so fed before many weeks are over. The author 
recently saw a case of dyspepsia brought about by feeding 
in this careless manner. On the other hand, the appa- 
ratus will serve as a guide to those physicians whose train- 
ing in percentage-feeding requires occasional assistance. 



('HAPTEE XXXIY 



Infant-stools. 



Stool of a JViirslinfj. — The stool of a nursling or a 
baby on an exclusiye milk diet slionld be yellowish in 
color, smeary or pasty-like in consistency, and have an 
acid reaction. The smell shonld be faintly acid, but not 
disagreeable. The color is due to bilirubin, and the re- 
action depends on the presence of lactic acid, the source 
of which is the milk-sugar. The only gases present are 
H and COo. According to Escherich, HgS and CH^, to 
which the odor of adult stools is due, are not present. 
There are no peculiar albuminoids. Those existing in 
mothers' milk seem to be entirely absorbed. Peptone ex- 
ists in trifling amount. Sugar is not present. Pancreatic 
ferment is absent, and sometimes traces of pepsin have 
been found. Mucus is always present in considerable 
quantity; also cokmmar intestinal epithelium. 

In the stools of nurslings large quantities of lactate 
of lime can be found; so also we frequently find oxalate 
of lime, depending on the quantity of oxalate of lime in- 
gested. Uffelmann has noted the presence of bilirubin 
crystals in the stools of nurslings, in perfectly-healthy 
children. 

Miller, who carefully studied the various micro-or- 
ganisms in the mouth, found that most of them could 
again be found in the intestinal canal. He further found 
that certain germs possessed diastasic properties and 
were capable of producing lactic-acid fermentation. In 
the milk-faeces of nurslings Escherich found two germs; 

(265) 



'M 



INFANT-FEEDING. 



the one lie called bacterium lactis aerogenes (or bac- 
terium acetieum^ Baginsky) and the other the bacterium 
coli commmie. In the meconium he found proteus vul- 
garis, streptococcus coli gracilis, and bacillus subtilis. 
The number of stools during the first two weeks is from 
3 to 6 daily. After the first month the average is 2 stools 
daily; many infants have 1, others 3 stools daily. This 
latter is due largely to the excessive quantities of water 
o-iven to infants. 




Fig. 38. — Schering's Formalin Disinfecting-lamp. Well Adapted 
as a Deodorizer in the Nursery. 



As soon as the exclusive milk diet is changed to the 
mixed diet we then lose the characteristic infantile stool 
and they resemble more those of an adult, though remain- 
ing softer and thinner throughout infancy. They become 
darker in color, assume the adult odor, and have more 
varieties of bacteria than those previously mentioned as 
found in the stool of a milk diet. 

Reaction of Stools. — Eeaction of stools in diarrhoeal 
disease and in health is chiefly acid or. next in frequency, 
neutral. Alkaline stools are rare. Green-grass stools, 



INFANT-STOOLS. 267 

usually acid, are seen in the early stage of dyspeptic diar- 
rhoea, the color from a pale greenish yellow to grass- 
green, owing to improper food. 

Wegscheider has shown that the green color is the 
result of preformed biliverdin. The condition in the in- 
testine, upon which the transformation of bilirubin into 
biliverdin depends, has been generally regarded as one of 
acid fermentation. 

Experiments. — Pfeiffer's experiments*^- show this for- 
mer opinion to be wrong. He found that none of the 
acids formed in such fermentation — lactic, acetic, butyric, 
propionic, etc. — added to yelloAv stools outside the body, 
turned them green, but that they made them deeper 
yellow. But dilute alkaline solutions added to fresh 
yellow stools turned them green after an exposure of 
thirty to sixty minutes, and strong solutions turned them, 
first, brown; later, after exposure to air, intense green. 

Typical Green Stools. — Typical green stools can be 
produced by giving an infant 2 or 3 grains of bicarbonate 
of soda. This I have tried dozens of times; the soda must 
be given for a few days. This explains Pfeiffer's alkaline 
theory. Typical green stools can also be produced by 
giving small or even large doses of calomel. If, after 
having given bicarbonate of soda and produced green 
stools, we give diluted hydrochloric acid in 5- to 10-drop 
doses, the yellow color will in a few days again reappear. 
This is also true in giving rhubarb. 

Stoots. — Stools which are pale yellow when dis- 
charged, and which afterward become green, are often 
seen in disease. Thev may be themselves neutral or alka- 



"^ "Verdauung im Sauglings-alter bei Krankhaften Zustan- 
den," "Jahrbnch fiir Kinderheilkunde/' B. 28, page 164. 



268 INFANT-FEEDING. 

line in reaction; this latter may, however, depend on the 
admixture of nrine. An excess of bile may often cause 
very green stools. 

Bj'oirn Stools. — Brown stools may be due to changed 
biliary pigment and to drugs-' i.e., bismuth causes the well- 
known dark stool. So also tannic acid and all iron salts 
give the dark stool, Avhich varies from a deep brown to a 
black color. 

Blood in Stools. — Blood from the stomach or small 
intestine frequently gives the stool a black color resem- 
bling tar. Thus, a practical point in Boas's "Diagnostik 
der Magen- und Darmkrankheiten" is that, the brighter 
the color of the blood, the lower down near the rectum 
and anus must the pathological lesion be looked for; the 
darker the blood, the higher up must the cause be found: 
e.g., the diseased conditions exist in the stomach, duode- 
num, jejunum, etc., if the stool contain black blood. If 
the corpuscular elements of the blood are wanting, then 
the presence of blood can only be positively diagnosti- 
cated by either a microchemical examination or by means 
of the spectroscope. The presence of red blood-corpuscles 
must always be regarded as a pathological factor. 

Brown Stools; MuHdy Stools. — A brown stool in an 
infant is frequently caused by a diet of animal food or by 
a diet principally of broth. These stools have no distinct 
consistency nor reaction. In dyspeptic diarrhoea or in 
some forms of enterocolitis we have very offensive stools, 
and they resemble muddy water; with the latter there is 
considerable flatus during each movement. 

White or Light-Gray Stools. — White or light-gray 
stools usually are of a putty-like consistency, sometimes 
like dry balls on a diaper; sometimes they appear like 
ashes. Usually they are very offensive, consisting prin- 



INFANT-STOOLS. 269 

cipally of fat. In the latter there is scarcely a trace of 
bile, or the latter may be absent altogether. 

Mucus. — Mnciis is always present in all healthy 
stools, and is so well mixed with the stool that it does not 
appear as mncus to the naked eye. Any appearance, 
therefore, of mucus easily visible should be regarded as 
abnormal. Mucus is present in every form of intestinal 
disease. Very abundant in inflammatory conditions af- 
fecting the large intestine, more so than in those affec- 
tions of the small intestine, and especially so in inflam- 
matory conditions of the colon, both acute and chronic. 

Jelly-like Masses. — Jelly-like masses of shreds of 
mucus, and where the stool consists chiefly of mucus, 
show that the affection is confined to the lower portion of 
the colon or that it is located in the rectum. 

Long Shreds of Mucus. — Long shreds of mucus, fre- 
quently resembling false membrane, are often found in 
catarrh of the large intestine. If the shreds of mucus 
are intimately mixed with the stool, then we must look 
for the lesion quite high up, and if it comes from the 
small intestine it is usually stained from bile. If the 
lesion is low down the mucus is not intimately mingled 
with the stool. 

Dyspeptic Stool. — The first change noticed in the 
dyspeptic stool is the increase of fat. Often the stool is 
quite green and contains small pieces, of yellowish-white 
color, which vary in size from that of a pin-head to the 
size of an ordinary pea. Hitherto, from their color, they 
Avere supposed to be casein lumps. Wegscheider has 
taught us that they consist principally of fat. Baginsky 
has shown that large colonies of bacteria are contained 
in these hmips of fat. Frequently they are so numerous 
that it looks as though the stool were composed only of 



270 INFANT-rEEDlNG, 

these cheesy lumps. They can be easily differentiated 
from real casein lnm])s by their solubility in alcohol and 
ether. 

Fat Diarrha'a.—BiedeTt and Demme have devoted 
considerable attention to this subject. ^^ In some children 
the faeces showed 50 to 60 per cent, of fat^ whereas the 
normal percentage in ordinary faeces varied from 13.9 per 
cent, (which is the normal quantity)^ according to Uff el- 
ma nn. 

Casein is not nearly as common an ingredient of 
faeces as is commonly supposed, as I have previously 
stated. Casein lumps can be seen in abundance in the 
course of a diarrhoea during an exclusive diet of milk. 

Quaniity of Fceces. — The quantity of faeces varies, 
but it has been found that 100 grammes of milk-food will 
produce about 3 grammes of faeces, according to Baginsky. 
This is a vital point, but I have found it very difficult to 
determine, for in most cases the napkins of the infants 
are soiled with urine plus the faeces, thus adding to the 
gross weight. 

Proteids. — The proteids of milk are so thoroughly 
absorbed that only small traces of them can be found in 
the faeces. N'ormal milk-fseces contain large quantities of 
bacteria, but chiefly two kinds, previously mentioned, viz.: 
bacterium lactis aerogenes (Escherich) and bacterium, coli 
commune. Other germs, especially those of the proteo- 
lytic type (i.e., those that render gelatin fluid), are not 
found under normal conditions. 

Albuminous decomposition and its products — tyro- 
sin, indol, phenol, and skatol — are not found in milk- 



'^^ See Biedert : "Fett-Diarrhea," in " Jahrbuch f iir Kinderheil- 
kunde," 1878. 



INFANT-STOOLS. 271 

faeces. But lactic acicL acetic acid, formic acid, and otlier 
fatty acids are present, causing the acid reaction. 

Saccharin Fennent. — Yon Jakscli found a saccharin 
ferment in the faeces of children. 

Pepto7iizing Ferment. — Baginsky found a peptonizing 
ferment also in infantile fseces. 

Escherich^* says: "If albuminous decomposition with 
very foul offensive stools exists, these articles should he 
withheld from the diet and carbohydrates given, dextrin 
foods, sugars, and milk. If acid fermentation is present, 
with sour, but not offensive, stools, carbohydrates are to 
be withheld and albuminous foods given, such as animal 
broths, bouillon, peptones, etc. In the decomposition of 
milk, the sugar of milk, and not the casein, is usually 
broken up.'' 

Holt-""^ says: "Eegarding the exact indications ac- 
cording to which fat, sugar, and proteids of milk are to 
be varied, mucli remains to be learned." 

Sugar is Tew Low. — If the sugar is too low, the gain 
in weight is apt to be slower than when furnished in 
proper amount. 

Sugar in Excess. — Symptoms indicating an excess of 
sugar: Colic or thin, green, very acid stools, sometimes 
causing irritation of the buttocks: sometimes there is re- 
gurgitation of food and eructations of gas. 

Excess 'of Fat. — Excess of fat is indicated by the fre- 
quent regurgitation of food in small qtiantities, usually 
one or two hours after feedino-. Sometimes an excess of 



^"Jahrbuch fiir Kinder heilkunde/"' "Beitrage zur Antisep- 
tichen Behandlungs-metliode der Magen-Darmkrankheiten des 
Saiiglingsalters." 

«= "Artificial Feeding," page 179. 



272 JNFANT-FEEDING. 

fat causes very frequent passages very nearly normal in 
appearance. In some cases the stools contain small round 
lumps somewhat resembling casein, but really masses of 
fat. This has already been mentioned in speaking of the 
differentiation of true casein curds and small fat lumps 
by the solubility of the latter in alcohol or ether. 

Dry, Pasty Stools. — When too little fat is given, it is 
indicated by hard, dry, pasty stools, and nsnally constipa- 
tion. This can be easily remedied by the addition of 
cream three-fifths of which is fat. Holt speaks against 
increasing the fat above 4.5 per cent, in infants under six 
months old, and believes we should not go above 4 per 
cent. 



CHAPTEE XXXY. 

Nathais' Straus Milk-laboeatories and Similar 
Charities. 

Since 1894, through the generosity of the Hon. 
Xathan Straus, pasteurized, modified, and natural milk 
has been supplied from laboratories and milk-depots scat- 
tered throughout N'ew York City. Some of these are 
found in the different parks of the crowded portions of 
our city. Hundreds of thousands of bottles are dispensed 
annually in Xew York and in neighboring cities. Thus, 
in a report of the Board of Health of Brooklyn for the 
year 1895, we find that in Brooklyn 42,739 bottles were 
used. - 

The infant-mortality has certainly been lessened dur- 
ing the last few years in these cities; a great deal of it is 
due to the education of the poorer classes living in tene- 
ment-houses, by means of these laboratories, to the neces- 
sity of using boiled food, or, call it sterilized milk, and 
boiled water. There are other factors which have less- 
ened the great infant-mortality in ISTew York City. 

Do not let us forget the difference in the cleanliness 
of the streets of this metropolis due to the energetic work 
of the late Colonel Waring. The weeding out of blocks 
of tenement-houses, and the substitution of small parks 
in the heart of the tenement-district must certainly be 
considered. Whoever studies the development of rickets 
will find that it is not only the feeding which is the prime 
factor, but it is the environment, the faulty dwelling, with 
its foul air and general unsanitary condition, that con- 

(273) 



2T4 iNFANT-FEEDING. 

tribute to the poisoning ol the air Lreatlied by the infant; 
this poisoning is as distinct a toxwmic condition as it would 
be if a poison were injected directly into the body. Faulty 
food^ be it breast-milk or cows' milk^ is the prime factor. 
Having been on continuous duty in the children's 
service of one of the largest clinics in this city for over 
ten years^ the author has noted many, many changes. In 
recent years the large number of excursions, notably the 
St. John's Guild, which gives an excursion every day dur- 
ing the hot summer months to the poor destitute children 
of our city, has certainly added to the health of many 
little ones. There are also numerous sectarian excur- 
sions; so, for example, there is a Hebrew Sanitarium giv- 
ing excursions to Eockaway every day during the summer. 
Then there are numerous church excursions and fresh-air 
funds, notably the ISTew York Herald Ice Fund, all of 
which have a tendency to invigorate the lives of these 
poor infants, and in this manner they can withstand the 
terrible heat of the summer months, and survive it. The 
sanitary vigilance of the Board of Health of New York 
City has certainly improved the sewage and drainage, looked 
after the water-supply, and certainly benefited the city. 
These factors must be taken into account in studying the 
mortality and the population. The blessing for New- 
York City will consist in giving it a pure, clean, and rich 
milk in which the stable, and cow, and milker's hands and 
all utensils are absolutely sterile. I cannot emphasize too 
strongly that the ideal milk of the future will not be ster- 
ilized milk, not pasteurized milk, but will be 'pure, raw milk. 
Nature supplies her infants in the human breast with raw 
milk at body-temperature; why must we feed our infants 
with boiled or steamed milk, especially so, when chemists 
have taught us that chemical changes take place in boiled 



MILK-LABORATORIES. 275 

as well as in sterilized milk, rendering the milk more indi- 
gestible than it was in its raw state? 

A vital point to remember is that the milk, when 
drawn from the cow, mnst be quicMy cooled and must not 
be allowed to reach a temperature above 50° F. until used. 

Such milk will not permit the development of bac- 
teria — dangerous to health. 

Eapid cooling, then, — to repeat again, — ^is as important 
as the absolutest assurance of cleanliness and sterility of 
every utensil brought in contact with milking, — so neces- 
sary to avoid introduction of filth or bacteria. 



CHAPTEE XXXVI. 



Colic. 



Colic is one of the most frequent causes of crying in 
children. They not only cry loudly^ but will suddenly 
shriek^ and when put to sleep will awaken with a sudden 
start, and cry loudly. The legs are usually flexed or they 
will move their legs back and forth, or up and down. They 
will seem to bend the body on itself. These attacks are 
usually associated with constipation; hence, it is a good 
plan, when the child is restless and utters a painful cry, 
to see if the bowels have moved. It is well known that 
this colic may be as well associated with diarrhoea. The 
origin of all colic is certainly the stomach. When dys- 
peptic conditions, arising from undigested particles of food 
in the stomach, exist, then fermentation, resulting in gas- 
formation, is the result. Colic is frequently known by the 
terms of ^^meteorismus or tympanites," but in the latter 
conditions the abdomen is greatly distended, and there 
is a permanent enlargement of it. Borborygmus can usually 
be made out, if the ear is applied to the abdomen. The vast 
majority of cases of colic have their seat in the intestine, 
and can b@. relieved very quickly. 

Worms (ascarides) have been known to cause colic. 
Besides, when there is a general loss of tone on the part 
of the muscular layers in the walls of the intestine, colic 
will frequently result. Jacobi believes that chronic peri- 
tonitis resulting in adhesions, or such local changes in the 
walls of the intestine that will produce local contractions 
or dilatations, can cause colic. 

The treatment of colic is simple when the cause is 
known. The quickest method of relieving colic is to give 
an enema of soap and water or of warm chamomile-tea. 

(37G) 



COLIC. 277 

I usually take an ounce of German chamomile-flowers and 
steep it in a quart of boiling water for from ten to fifteen 
minutes, and then strain. The injection is to be given 
in the same manner as will be described in detail in 
the chapter on constipation. My method is to allow 1 
or 2 pints of chamomile-tea at' a temperature of 100° to 
110° (no hotter) to flow slowly into the rectum, and by 
all means the colon. When the colon is thoroughly 
flushed with this warm tea, and emptied of its faeces, it 
is usual for the attack of colic to cease. In addition to 
washing the colon, it is a good plan to apply a small bag 
of either chamomile-flowers or slippery-elm bark, or 
ground flaxseedmeal. To do this, I make a bag of cheese- 
cloth, capable of holding from 1 to 2 ounces, and then fill 
it with one of the above-mentioned ingredients; sew the 
bag shut when filled, and heat it before applying to the 
abdomen. Several of these bags can be made and kept 
in readiness, so that they can be applied quickly. It is a 
good plan to. have one heating on the stove, while another 
is on the abdomen. These little bags are very grateful, 
and we are frequently rewarded by having the infant not 
only expel wind shortly after they are applied, but also 
frequently fall asleep. 

MASSAGE. 

During an attack of colic gentle massage with warm 
sweet oil or melted vaselin or lard will certainly be very 
comforting to the child. My plan is to take a bottle. of 
oil, warm it by placing it in a kettle of warm water, and 
then to pour it on the abdomen. The distended abdomen 
should then be thoroughly kneaded, and the gas expelled. 
Then the warm applications mentioned above can be 
applied. 



278 INFANT-FEEDING. 

DRUG TREATMENT. 

If the colic originated from a fermentative dyspepsia, 
then treatment must be directed to the stomach. For 
this purpose antifermentatives, like the mistura rhei et 
sodse, should be given in doses of Vo to 1 teaspoonful, di- 
luted with water, every two or three hours until there is 
a thorough evacuation. Very good results will be found, 
after the bowel has been cleaned with the quart of cham- 
omile-tea previously mentioned, by administering from 5 
to 10 grains of bismuth; I prefer to use betanaphthol or 
the subnitrate; ^/g-grain doses of resorcin will also be 
found useful. Paregoric in doses of 15 drops to ^/o tea- 
spoonful should be administered with great caution to 
children of six months or older. It is self-understood 
that no physician will forget the danger of giving repeated 
doses of paregoric or permitting the same to be admin- 
istered by incompetent people not aware of the dangers 
of the drug habit. The author has not only seen distinct 
opium poisoning follow the use of paregoric, but has also 
had occasion to see the distinct opium habit in very young 
children. This was reported by the author in a paper read 
before the New York County Medical Society, January 
22, 1894, and which was published in extenso in the Med- 
ical Record ot February 17, 1894. For an infant during 
the first few months, it is hardly safe to give more than 
5 drops of paregoric repeated in an hour, if there is no 
relief. Another drug that has served the author very 
well is Hoffmann's anodyne in doses of from 1 to 5 drops, 
repeated in an hour if necessary. For an infant up to 
two months 1 drop per dose; from two to four months, 
2 drops per dose; four to six months, 3 drops; six to nine 
months aud until one year of age, 4 drops; children from 



COLIC. 379 

one to two years, 5 drops. This is to be given in a tea- 
spoonful of sterilized water. Another valuable drug, and 
one that is to be given cautiously, and in the same doses 
as Hoffmann's anodyne, is spirit of chloroform; never 
should more than from 1 to 4 drops be given to a child 
up to one year of age, and younger children less in pro- 
portion. I cannot favor the administration of nauseating 
or foul-smelling drugs, such as asafoetida. We must try 
to cater to an infant's taste, especially so when in pain. 

THE USE OF SUGAR. 

When colic is caused by an excess of sugar, there will 
be quite some eructations of gas, and, frequently, small 
quantities of food will be regurgitated. 

The stools, when an excess of sugar is given, are thin, 
greenish, smell very acid, and usually produce a reddened 
excoriation of the buttocks and around the anus. 

When children show a tendency to the development 
of gas and have constant recurring colic, my plan is to 
discontinue the use of sugar, until such time when this 
fermentation is absent. To sweeten the food I use small, 
saccharin tablets, 1 tablet being ample to sweeten 1 pint 
of food. When there is a tendency to constipation, we 
cannot only sweeten the food, but modify this constipa- 
tion by adding 1 teaspoonful of pure glycerin to each 
bottle of food prepared. 

EXCESS OF PROTETDS. 

A careful observation of the stools would easily show 
whether the albuminoids are in excess, for they are 
usually present in the form of curds. This condition 
usually is associated with constipation, and the indication 
would be to cut dowu the quantity of enrd administered. 



CHAPTEE XXXVII. 



Constipation-. 



To CONSIDER the cause of constipation during the 
nursing period let us first look into the mechanical cause. 
Concetti/^ in a very elaborate article, gives the various 
anatomical reasons for constipation. He states that 
Huguier, in the Bulletin de VAcademie de Medecine, had 
reported this same pathological condition several years 
prior to Jacobi, of New York. Thus, Huguier advises, as 
a practical point, that when a colotomy was to be per- 
formed in an infant it would be wiser to perform the 
same on the right side rather than on the left. He stated 
that it was much easier, owing to the greater number of 
flexures, to jreach the same by operating on the right side 
in cases of atresia of the anus. Concetti further states 
that Jacobi, in 1868, reported in the American Journal of 
Olstetrics an elaborate article, which has since appeared 
in the "Therapeutics of Infancy and Childhood" (A. 
Jacobi, 1887), giving the anatomical reasons in detail. 
They are well worth noting: — 

The embryonic intestine is formed in separate di- 
visions. There is no ascending colon up to the fourth or 
fifth month of foetal life. It is very short in the mature 
newborn. Despite this, the large intestine of the mature 
foetus is longer in proportion than that of the adult. It 
is three times as long as the body of the foetus, while 
it is only twice as long in the adult. 



""Archiv fiir Kinderheilkunde, vol. xxvii, 1899. 

(280) 



CONSTIPATION". 281 

There is the same disproportion with regard to the 
length of the small intestine. The small intestine of the 
foetus in the ninth month is twelve times as long as its 
body. The small intestine of the adult is only eight 
times as long as the body. 

The colon ascendens being very shorty the surplus 
of lengthy particularly as the tra;isverse colon also is not 
long, belongs to the descending colon, and especially to 
the sigmoid flexure. Drandt found it between 8 and 2-i 
centimetres in length, averaging from 14 to 20. I have 
seen a case in which it was 30 centimetres long. 

As the pelvis is very narrow, the great length of the 
lower part of the large intestine is the cause of multiple 
flexures, instead of the single sigmoid flexure of the adult. 
Thus it is that, now and then, two or even three flexures 
are found, and to such an extent that one of them may 
be found to extend as far as the right side of the pelvis. 
Cruveilhier and Sappey speak of this position of the lower 
part of the intestine in the right side of the pelvis as an 
anomaly. Huguier finds it on the right side of the body 
in the majority of cases. Others only occasionally, al- 
though they admit the great length of the sigmoid flexure. 
In common with Huguier, who even proposes to operate 
for artificial anus in the right side, I have found one of 
the flexures on the right side many times. 

The great length of the large intestine and the multi- 
plicity of its flexures are of great functional importance. 
At all events, they retard the movement of the intestinal 
contents, facilitate the absorption of fluids, and thus the 
faeces are rendered solid. AVhen this length is developed 
to an unusual extent, constipation is the natural result. 
In the American Journnl of Obstetrics, August, 1869, I 
have described two cases in which the descendino- colon 



282 INFANT-FEEDING. 

was so long that the diagnosis of imperforate rectum was 
made. In one of them the operation for artificial anus 
was performed. Such cases and such errors are certainly 
very rare;' still they are those in which normal anatomical 
conditions will lead to incidents of great pathological im- 
portance. 

Other cases of constipation in the infant may he 
classed under four heads: — 

First. — The intestinal mucus is deficient or too vis- 
cid. Such is the case in fehrile conditions^ now and then 
in chronic intestinal catarrh, and also when there is too 
much perspiration and secretion of urine. 

Second. — Improper condition of food. A super- 
abundance of casein, particularly cows' casein; of starch; 
the absence of sugar, and the administration of astrin- 
gents and iron. 

Third. — Incomplete peristalsis, such as exists in the 
rachitic debility of the muscular layer, in the musculai- 
debility dependent upon sedentary habits and peritonitis, 
intestinal atrophy, and hydrocephalus. 

Fourth. — Mechanical obstruction. Cystic tumors in 
the intestine. There is, further, intussusception and twist- 
ing of the intestine, incarcerated hernia, even umbilical 
hernia, hardened f^ces, and imperforations. 

In all these cases the diagnosis should not be made 
without manual examination. In most of the cases the 
abdomen is inflated, though it be painless. The faeces 
come away in small, hard lumps or in large masses. The 
liver and spleen are displaced. The liver may be so 
turned that a part of its posterior surface comes forward. 
The abdominal veins are enlarged to such an extent 
that they form circles around the umbilicus, similar to 
what is seen in hepatic cirrhosis. These cliildren lose 



CONSTIPATION. 283 

their appetite, sometimes vomit, and the irritation pro- 
duced by the hardened masses in the intestinal canal may 
be such as to finally result in diarrhoea, which, however, 
is not always sufficient to empty the tract. 

There is, besides, an apparent constipation, which 
should not be mistaken for any of the above varieties. 
Xow and then a child will appear to be constipated, have 
a movement every two or three days, and at the same 
time the amount of faeces discharged is very small. This 
apparent constipation is seen in very young infants rather 
than in those of more advanced age. Such children are 
emaciated, sometimes atrophic. They appear to be con- 
stipated because of lack of food, and not infrequently this 
apparent constipation is soon relieved by a sufficient 
amount of nourishment. 

Constipation resulting from a superabundance of 
starch in the food is easily cured by the withdrawal of the 
latter. 

Constipation produced by too much casein in the 
food will be relieved by diminishing its quantity. The 
proportion of casein in the food of infants should never 
be more than 1 jDer cent. Besides, this amount of casein 
ought to be copiously mixed with a glutinous decoction. 

Infants that have been fed on starchy food or even 
such cereals as barley, should have oatmeal substituted 
for the barley. 

Constipation depending on lack of sugar is very often 
speedily relieved by increasing the quantity of sugar in 
the food. This is the case, not only in artificial feeding, 
but also when the children are fed normally on breast- 
milk. Such mothers' milk as is white and dense, and con- 
tains a large amount of casein, is made more digestible, 
and will produce better evacuations, when a piece of loaf- 



284 INFANT-FEEDING. 

sugar dissolved in tepid water is given immediately before 
nursing. 

As there is frequently a large excess of acid in the 
intestine^ magnesia with or without rhubarb will fre- 
quently relieve the acidity and cause a movement of the 
bowels. 

In a previous section on "Cream" I have already 
spoken of the deficiency of fat, which is one of the most 
frequent causes of constipation. Hence, in an infant 
nursing at the breast it is wise to give the child a tea- 
spoonful of raw cream immediately before taking the 
breast to correct the constipation. Cream consists of so 
much fat that in this manner we add fat directly to our 
food. This is the secret of success attained by some 
authors when they advise giving codliver-oil, butter, 
olive-oil, or fried bacon to very young children. Each one 
desires to remedy the deficiency of fat in his own particu- 
lar manner. 

A DRINK OF WATER. 

From infancy, when the child is but a few days old, 
we should make it a rule to give it a drink of water; thus 
a very small infant during its first week can be given two 
to three teaspoonfuls of boiled water during the day. A 
safe plan is to give this drink of water when it is not time 
for feeding, and if the child appears restless. It is 
understood that we must first satisfy ourselves that the 
child has not had a stool, is not lying in a soiled napkin, 
and that other conditions — such as colic — do not cause 
uneasiness in the baby. When a child is several months 
old, the quantity of water can be increased from teaspoon- 
fuls to as many wineglassfuls. Frequently have I noted 



CONSTIPATION. 285 

the disappearance of a continued constipation after giying 
an infant its ^^drink of water'' regularly. 

IMMEDIATE RELIEF OF CONSTIPATION. 

A rule that I have always followed, and one that I 
lay stress upon, is never to allow a child to retire at night 
without having had a movement of the bowels during the 
day. The reason for this is plain; not only will the ac- 
cumulated fseces and gas cause flatulence, colic, and un- 
easiness, hut this constant distension of the bowels will 
dilate the intestines to such a degree that frequently a 
permanent pendulous belly remains. 

My plan is to order an injection of a half -tumbler 
of ordinary glycerin mixed with a pint of warm water, — 
temperature, 100°, — and allow this quantity to flow into 
the rectum by using; a fountain-syringe, the end of which 
has the smallest infants' rectal nozzle. In this manner 
we have a rapid emptying of the rectum and colon, and 
can be assured of temporary and possibly permanent relief. 
It is not absolutely vital to use glycerin and water, for a 
similar result can be obtained if we make soap-water by 
rubbing up a piece of Castile soap with a pint of warm 
water, or using glycerin soap with the equal quantity of 
water, if the latter can be procured. 

Continued Use of Eiiema. — In obstinate cases it is 
well to slip a soft-rubber rectal tube over the nozzle, and, 
having anointed the rubber tube with vaselin or glycerin, 
the same can be pushed slowly into the rectum, then allow 
about half a pint of water to flow into the rectum, which 
will distend it graduall}^, and, by simply pushing the tube 
farther into the colon, we can allow the balance of 1 pint 
or more to flow directly into the colon. The continued 
use (daily) of these enemas is not fraught with danger; 



286 INFANT-FEEDING. 

on the contrary^ these rectal injections can be used for 
months. In safe hands, if the mother or nurse is intelli- 
gent, there should not only be no injury, but positive 
good, from its continued use. 

REMOVAL OF SCYBALA. 

Hardened round balls or fragments of fasces will fre- 
quently be caused when the stool remains very long in 
the colon, or when the sigmoid flexure has an unusual 
length; in such instances the injection of either ^/o pint 
of lukewarm sweet oil or glycerin will soften these scybala 
and aid in their expulsion. At times these balls will be as 
hard as marbles, and may require the aid of a small scoop 
(a very small teaspoon will do) to aid in their removal. 

DRUG TREATMENT. 

A great many drugs are indicated and counter-indi- 
cated in the treatment of constipation. The intelligent 
practitioner does not desire merely one movement of the 
bowels, brought about by drugs, but seeks rather to use 
such therapeutic measures which will give a permanent 
cure. My choice of drugs is the following: — 

B^ Ext. cascara sagrada fl., Sj- 
Glycerin, Bj. 

Mix. Twenty drops of the above mixture in a teaspoonful of 
water three times a day, for children about three months old. At 
the age of six months, double the dose, or 20 drops three times a 
day. At the age of one year a teaspoonful three times a day. 

My plan is to give the firse dose in the morning be- 
fore the feeding, and note the result. If the bowels move 
by noon-time then I discontinue the dose at noon, and give 
a second dose in the evening. If, however, there is no 
effect by noon-time, then I continue my second dose, and 
follow with my third dose in the evening. Thus, it will be 



CONSTIPATION. 287 

apparent that, if oue dose answers for the day, then we 
should discontinue the medicine for that day, but com- 
mence again on the following day, and keep up this form 
of drug treatment until it is apparent that the bowels are 
not as sluggish in their action as before. Another drug 
which has been one of my stand-bys for many years is nux 
vomica; thus, I give 1 drop of the tincture of nux vomica 
in a teaspoonful of sterile water three times a day, for 
an infant up to one year of age. Children of two years I 
give 2 drops three times a day. From three to six 
years, 3 drops three times a day. Six to ten years, 4 drops 
three times a day. Ten to fifteen years of age, 5 drops 
three times a day. ^ux vomica is always to be adminis- 
tered on an empty stomach. In other words, before feed- 
ing. Another valuable drug is rhubarb in the form of the 
aromatic syrup of rhubarb. From ^/^ to 1 teaspoonful 
once or twice a day, repeated every two days, will fre- 
quently afford relief. 

Powdered rhubarb and magnesia, given in teaspoon- 
ful doses to very young children, is one of the best laxa- 
tives and antifermentatives that we possess. It is espe- 
cially indicated for the relief of colic. 

Citrate of magnesia, given in wineglassful doses to 
children over one year of age once or twice a day, can 
also be recommended. 

In atonic conditions of the bowels depending on gen- 
eral weakness, strychnine, given in ^/^oo grain twice a day, 
will be found useful. This may or may not be combined 
with iron. 

The infusion of senna-leaves is made by boiling a 
heaping teaspoonful of ordinary senna in a teacupful of 
boiling water for fifteen minutes, straining, and when cool 
adding 1 tablespoon of glycerin to 5 tablespoons of this 



288 INFANT-FEEDIN'G. 

infusion of senna. This quantity to be administered in 
three doses at intervals of four or five hours. In some in- 
stances the addition of syrup of manna will be found ad- 
vantageous in sweetening the infusion of senna. 

Certain drugs should not be given. Of these castor- 
oil may serve as a type. The constipating effect following 
the use of castor-oil is so well known that this drug is in- 
dicated when we wish to cleanse the stomach and bowels 
and remove stagnant food^ as, for example: in fermenta- 
tive dyspepsia accompanied by diarrhoea. Thus, we not 
only have an effective movement, but a constipating effect 
following the same. The use of drastic cathartics — such 
as scammony, elaterin, or podophyllin — should not be 
thought of in the treatment of infants and children. Very 
rarely do I use aloes, owing to its offensive taste. It is 
understood that calomel is only to be given when we 
wish to cleanse and produce an antiseptic effect in the 
intestine, but, for the treatment of constipation per se, 
calomel is entirely out of place. 

Suppositories. — i^mong those most commonly used 
are suppositories of the glycerin and gluten type. Most 
suppositories in the market are entirely too large, and 
frequently must be cut into halves and quarters. The 
suppository made by Parke, Davis & Co. has served the 
author very well. It should be distinctly understood that 
a suppository is to be used in the evening for the same 
relief as we desire from the injection or enema previously 
mentioned. Neither the suppository nor the injection 
should be used with the idea of curing a constipation. 

MASSAGE. 

Continued kneading of the abdomen with the aid of 
vaselin or oil will be found serviceable, and, if properly 



CONSTIPATION. 289 

done^ will provoke an action of the bowel. Thus it is that 
rubbing the abdomen with castor-oil has frequently been 
recommended in the treatment of constipation; the eSeet 
supposed to be due to the castor-oil is, in reality, du.e to 
the massage, and to nothing else. A¥lien massage is used, 
it should be continued from five to ten minutes every day 
for one month, morning and evening. This will certainly 
aid and stimulate peristalsis, and ultimately tone the 
muscles and cure the constipation. 

ELECTEICITT. 

This is very valuable to stimulate peristalsis. The 
faradic and galvanic and static currents can be used. For 
the general practitioner the use of the galvanic current, 
five to ten cells, is sufficient. The negative pole (cathode) 
should be applied in the rectum, and the positive pole, 
which produces peristaltic waves, should be applied over 
the ascendino-, descendino-, and transverse colon. Local 
contractions result from the negative pole. A gentle 
faradic current applied over the spine and the abdomen 
will answer if used for several minutes in the absence of 
the galvanic current. Galvanic electricity should be used 
every day; frequently months are required to insure a 
cure, in conjunction with the medicinal and dietetic treat- 
ment. 

DIETETIC TREATMENT. 

We have previously mentioned the value of cream, 
and the addition of water for the treatment of constipa- 
tion. In bottle babies it is w-ell to remember that oatmeal- 
water and sago-water should be used when constipation 
exists. Under no condition should barley or rice be 
given, as the latter will simply increase the constipation. 



'390 TNFANT-FKEDING. 

Older cliildreii sliould be given fruity baked apples^ 
peaclies, prunes, grapes, and oranges, and avoid pears. 
Buttermilk will be found serviceable, as well as koumiss, 
for the relief of constipation. Sugar (cane-sugar) will be 
found quite serviceable, when added to water, for the 
relief of constipation in nursing or bottle-fed babies. 
Thus, a good plan, according to Jacobi, is to give a small 
piece of loaf-sugar dissolved in water immediately before 
nursing, and to substitute and use cane-sugar instead of 
milk-sugar for bottle-fed babies. 

Having regulated the diet and excluded fresh bread, 
cakes, pies, pastries, macaroni, and other floury foods, we 
should insist, in children over two years of age, on eating 
all green vegetables with the exception of cabbage, beans, 
turnips, potatoes, and corn. Thus, celery, spinach, green 
pease, asparagus, and cauliflower are recommended. 

EXEECISE. 

What massage is for a young infant exercise is for 
an older child. Thus, it is apparent that atonic con- 
ditions can best be relieved by combining the dietetic 
and medicinal treatment with out-of-door exercise. 
Children should be permitted to romp about and walk 
and play out-of-doors, but not to a point approach- 
ing fatigue. Older children will find bicycle exercise 
or horseback-riding decidedly beneficial. It is impor- 
tant, however, to regulate the amount of such exercise, 
and thus it is apparent that it is the physician's duty to 
tell the mother or nurse just how long a child should be 
])ermitted to exercise. It would seem that one-half hour 
twice a day is ample to arrive at beneficial results. Over- 
indulgence in such sports will frequently result in rupture 
and producinoj heart-strain. In cardiac lesions, in asth- 



CONSTIPATION. 291 

matic conditions^ if children suffer with whooping-cough, 
and in tuberculous conditions such exercises must not be 
allowed. 

HYGIENIC TREATMENT. 

We should insist on proper ventilation of a child's 
sleeping-room at night, and it is, therefore, advised that 
the window be left open a few inches. This is not 
fraught with danger; on the contrary, it is healthful and 
beneficial to allow children to play in the open air all day, 
and naturally to shut them up in poorly ventilated apart- 
ments at night is simply inviting both throat and lung 
trouble. In addition to proper ventilation, bathing in cool 
water or hikewarm water, followed by an abdominal spray 
or a douche directed against the stomach and bowels, will 
be found advantageous in the correction of this ailment. 
Following the bath, friction with a good, coarse, Turkish 
towel will be found useful. My preference has ahvays 
been for a lukewarm bath, followed by a cold douche for a 
few moments, every morning, and then to have the child 
properly rubbed until the skin is reddened with a Turkisli 
towel, followed by massage with oil or vaselin. 



CHAPTEE XXXVIII. 

Statistics. 

The recorded births of the three years 1890, 1891, 
and 1892, according to the Xew York Board of Health, 
were 135.602. 

It is estimated that this represents only five-sixths of 
the actual nnmber born; so that 162,721 would really 
represent the actual number of births for this period. 
During the same time the number of deaths of children 
under five years of age were 52,213, representing over 32 
])er cent, of the whole number of births. 

In July, 1893, the deaths of children under five years 
of age numbered 2796. During the same months of 1894, 
2562. In August, 1893, there were 1686. In August, 
1894. 1559. During eight months ending in August the 
deaths under five years of age were: 1895, 13,287; 1896, 
12,734; 1897, 10,962. During June, July, and August of 
1896 there were 5671 deaths. During the same period of 
1897, 5041. "1897 was a cool summer." 

The following tables, compiled from the vital statis- 
tics of the Board of Health, show the relative death-rate 
and the infant-population in New York City. 

Deaths and Death-rates of Children under Five Years 

OF Age, for the Months of June, 

July, and August. 

Year. Population. Deaths. Death-rate. 

1891 . 188,703 5,945 126.0 

1892 194,214 6,612 136.1 

1893 199,886 5,892 117.9 

(292) 



STATISTICS. 293 

Tear. Population. Deaths. Death-rate. 

1894 205,723 5,788 112f5 

1895 212,983 6,183 116.1 

1896 216,728 5,671 104.7 

1897 .220,641 5,041 91.4 

1898 ." 224,736 5,047 89.8 

1899 229,029 4,689 81.9 

1900 233,537 4,562 78.1 

Population, Deaths, and Death-eates of Children Under 
Five Years of Age from 1891 to 1899 
IN New York City. 

Year. Population. Deaths. Death-rate. 

1891 188,703 18,224 96.6 

1892 194,214 18,684 96.2 

1893 199,886 17,865 89.4 

1894 205,723 17,558 85.3 

1895 212,983 18,221 85.6 

1896 ....216,728 16,807 77.5 

1897 220,641 15,395 69.8 

1898 224,736 15,591 69.3 

1899 229,029 14,391 62.8 

The number of deaths until October 1, 1900, was 12,825 ; ratio 
about 70. This mortality is higher than in 1899, but during first 
four months of this year there was an excessive amount of respira- 
tory diseases, prevalence of grip, and also infectious diseases. 

The author desires to thankfully acknowledge the 
kindness of Drs. Gnilfoyle and Taylor, of the Xew York 
Health Department, in furnishing the above statistics. 



^ CHAPTER XXXIX. 

Kachitis (Rickets). 

Prof. Paul Zweifel, in his recent work (1900) on 
the above snbject, says: "That the addition of water to 
raw milk aids in the digestion of the same^ whereas^ the 
addition of an equal quantity of water to boiled niilk^ 
produces just the opposite effect." Thus it would appear,, 
from the experiments of this author^ that raw cows' milk 
diluted with an equal quantity or even more water will be 
much easier assimilated than diluted boiled milk. 

Zweifel agrees with Schlesinger, of Breslau, "that the 
addition of water to milk does not render it more di- 
gestible." Clinical investigations by such authorities as 
Professor Baginsky, in Berlin, have proved conclusively 
that wdiole milk (undiluted) cannot be fed to infants with 
weak digestive powers or those suffering with dyspepsia 
without aggravating the dyspeptic conditions and threat- 
ening the very existence of the child. Time and time 
again has the author tried to increase the weight of chil- 
dren and to strengthen them by giving them more con- 
centrated food. These experiments would have proved 
disastrous in winter but for the rapid withdrawal and sub- 
stitution of the requisite diluted milk solution necessary 
for the age of the infant. 

THE ADDITION OF TABLE-SALT. 

The addition of table-salt has given such satisfactory 
results when added to milk that Zweifel insists on its 
advantage in preventing rickets. When a large-size 
thimble is filled with salt it will hold about 3 grammes. 
The smaller thimbles will hold about 2.5 grammes of 

(294) 




Fig. 39. — Funnel-shaped Depression of Sternum. Rachitic Ky- 
phosis. Deformity of Spine. Picture also Illustrates Ra- 
chitic Square Head. (From Author's Service in Children's 
Department of German Poliklinik.) 



KACHiTiS. 295 

salt. If this quantity (3 grammes) of table-salt is added 
to 1 pint of water (500 cubic centimetres), then we liaA^e 
a solution approximating the decinormal salt solution 
commonly known as the physiological normal salt solu- 
tion. Zweifel maintains that both sterilizing and boiling 
the milk, according to the Soxhlet method, does not ren- 
der it more indigestible. On the other hand, he believes 
that the albuminoids of the milk are rendered more diffi- 
cult to digest, and thus he believes that boiling might bo 
a factor in producing rickets. 

Eickets is caused by the substitutes for milk rather 
than by milk itself. 

When children are improperly fed so that the body 
is underfed, muscle- and bone- formation will be slow. 
Thus it is that the eruption of the teeth will be delayed, 
and this is one of the most prominent symptoms of rickets. 
The bones show the most characteristic result of improper 
nutrition, for they are very soft and spongy. They will 
yield to the weight of the body if used in walking, and thus 
it is that bow-legs with extensive curvatures form such a 
prominent feature in showing the result of using soft bones. 
The most typical symptoms can be studied on the head and 
spine. Thus, craniotabes can be explained by a deficient 
nutrition in which the cranial bones will be found so soft 
that they will yield to the pressure of the thumb. The 
cranial bones will frequently be found to be as soft and 
as thin as pasteboard. The spine is most frequently de- 
formed, and will show a typical rachitic kyphosis. 

CAUSES. 

The majority of children suffering with rickets are 
or were bottle-fed children. Thus it is apparent that no 
food can equal breast-feeding, be it mother or wet-nurse. 



296 INFANT-FEEDING. 

in preventing rickets. There are a great many other 
causes, such, for example, as bad sanitary measures and 
faulty hygiene. Breast-fed ' children will sometimes show 
rickets when they have been living in bad apartments, 
breathing foul air, and not being properly cared for. One 
of the most frequent causes of rickets is "prolonged" 
nursing. In the section on "Breast-feeding" I have 
already pointed out the necessity for making a proper 
chemical examination of the breast-milk if the infant 
"shows no increase in weight." We know that, toward 
the end of lactation, not only do the proteids diminish, 
but get to such a low percentage that, unless we combine 
hand-feeding by adding the raw white of egg, steak-juice, 
and other proteids, like the cereals, to the nursing, the 
child will be underfed. This underfeeding is certainly a 
contributing factor^ both to the causation and leading to 
the development of rickets. 

Children that have suffered prolonged diarrhoeas or 
with severe diseases — like dysentery, typhoid, bronchitis, 
and pneumonias — are prone to the development of rickets. 
Children of syphilitic parents and whose parents are 
tuberculous are more prone to the development of this 
disease. Von Eitter, quoted by Professor Baginsky, says 
that, in twenty-seven cases out of seventy-one examined 
by him, rickets was not only found in the children, but as 
well in the mothers of these same cases. Thus it is that 
Kassowitz and Schwarz^^ have mentioned the existence of 
congenital rickets. This same author found that 80 per 
cent, of children born in the Vienna Lying-in Hospital 
were rachitic. This statement is not so easily accepted, 
however, for both Professors Baginsky and Virchow do 



'Wiener medicinische Jahrbucher/' 1887, vol. viii. 




I'^i-i. 40. — Ivifkets, showing IJeaded Ribs. liieast-Fcd Infant 
with Poor Hygienic Conditions and Delieato ]\rotli('r. 
(Fro)ii riiildicn's Scvxice of ricrnian I'oliklinik.) 



RACHITIS. 297 

not accept the same. Experimentally, it has been found 
as long ago as 1842 by Chossat that when lime is deducted 
from the nourishment of young animals not only soft 
bones result, but they finally die. Heitzmann maintains 
that, if lactic acid is introduced into the food of young 
animals, the result will be, first, rickets, and, later on, 
osteomalacia will result therefrom. Clinical investiga- 
tions haye shown that cases of rickets occu.r more often 
during the winter months; thus it is apparent that im- 
proper ventilation is one of the most exciting causes of 
this disease. 

The prognosis of infants suffering with rickets de- 
pends upon the amount of damage already done. If de- 
formities of the spine, of the head, of the legs, and arms 
exist, careful orthopaedic treatment will certainly modify 
the condition. The backbone of the treatment will, how- 
ever, consist in studying "the dietetic requirements of 
the case."^ In this disease more than in any other will 
the advantages of a carefully-regulated diet be apparent, 
if the hygienic factors and proper medicinal treatment are 
included. 

Eachitic children require milk, meat, and eggs; 
plenty of cereals, like wheat, barley, rice, farina, sago, 
oatmeal, hominy; they require butter, and, if they will not 
take butter, then codliver-oil or lipanin; iron will be found 
valuable, as well as Fellows's hypophosphites; malt- 
extract and ferrum lacticum are indicated. Great empha- 
sis must be put on the value of fresh air and sunshine in 
the treatment of this disease. 

EXTERNAL TREATMENT. 

Bathing in sea-salt, taking 1 to 3 pounds of salt to a 
bath-tub of water, to which malt-extract, about 1 teacup- 



298 INFANT-FEEDING. 

ful, is added; in the place of malt Baginsky advises 2 
ounces of calamus-root. I have seen very good results fol- 
low the continued use of bran and sea-salt, of which 2 to 
3 pounds of bran and a pound of sea-salt are placed in 
a bag made of cheese-cloth. This bag is put into the 
bath-tub one-half hour before putting the baby in it. 
Enough water is then added to bathe the child; the tem- 
perature of the bath to be from 80° to 100°, my pref^-- 
ence being for a cool bath, really tepid, temperature of 
80° F.; duration of bath, from 10 to 20 minutes, followed 
by a good, brisk rub with a coarse, Turkish towel. 

Massage of the muscles aided by passive movements 
wdll be found very valuable in producing a better muscular 
development, aiding metabolism and stimulating the cir- 
culation in general. The great susceptibility of rachitic 
children to colds and coughs, especially to croup, can cer- 
tainly be modified if such children will be given cold 
baths, cold sponging, cold spray, or a cold douche. Such 
children should not be overbundled with clothing, and 
while I insist on protecting the lungs and the whole body 
from sudden changes in the weather, the use of too much 
clothing will certainly tend to increase the amount of 
perspiration, and thus add to, rather than mitigate, our 
trouble. 

Kassmvitz Formulce. — 

1. ^ Phosphor! purl, 0.01. 

01. amygdal., 70.00. 
Sacch. alb., 30.00. 
^ther. fragar., gtt. xx. 

2. I^ Phosphor! puri, 0.01. 

Solve !n ol. amygdal. dulc, 10.00. 
Pulv. gumm! arab., 5.00. 
Sirup! simpl., 5.00. 
Aq. dest., 80.00. 




Fig. 41. — Sliowiiig Rncliitic IVaded Ribs on Left Side of Thorax. 



RACHITIS. 299 

3. I^ Phosphor! puri, 0.01. 
01. amygdal., 30.00. 
Pulv. gummi arab., 15.00. 
Sacch. alb., 15.00. 
Aq. dest., 40.00. 

Of the above mixtures^ 1 to 2 teaspoonfuls per day; 
so that children would receive Vg milligramme (0.0005) of 
phosphorus, and in prescribing 100 grammes of codliver- 
oil or in the emulsion containing the above-mentioned 
dose of phosphorus the quantity would last twenty days. 
Formula ISTo. 1, given by Professor Kassowitz, of Vienna, 
does not mix well; neither does Formula 3; so that For- 
mula 2 is the only one available for practical purposes, 
and may be used. A chemical test for the presence of 
phosphorus will always yield a positive result. Thus far 
the specific action of unoxidized pure phosphorus has not 
yet been proved. In fact, such keen observers as Baginsky 
and Henoch do not believe that phosphorus in its pure 
state is applicable. 

A very valuable drug in the treatment of rickets is 
the following: Glycerophosphate of lime, in doses of 1 
to 5 grains for an infant one year old, to be given im- 
mediately after feeding. For a child six months old one- 
half the dose. 

When this disease is associated with anaemia or very 
great weakness or where it is desirable to tone up the gen- 
eral system, then add to the glycerophosphate of lime an 
equal dose of the glycerophosphate of iron. This drug 
treatment should be continued for several months before 
expecting results. It is self-understood that the author 
insists on a radical change of diet, and also the strictest 
hygienic treatment^ when possible. All factors will be 
more essential than merely giving an infant a few doses 
of drugs. 



CHAPTER XL. 

Dentition (Teething). 

The teeth usually appear, according to Professor 
Baginsky, between the third and tenth months. Usually 
though, between the ninth and tenth months. The usual 
rule is for normal dentition to begin about the seventh or 
the eighth month. 

In a great variety of children premature teething is 
recorded; then I have seen a great many children born 
with two and more teeth. 

Eachitic children, as a rule, teeth very early or very 
late. 

In the large children's service with which I have 
been connected I have observed the eruption of teeth 
many times as early as two or three months in very 
rickety, bottle-fed children. These teeth soon decay, and 
are then known as carious teeth. 

In syphilitic (congenital) children premature denti- 
tion is frequently seen. The first teeth are known as milk- 
teeth. 

The following table will show the usual rule followed 
by normal dentition in the average child: — 

19 I 11 I 13 I 5 I 3 I 4 I 6 I 14 I 9 | 17 
20"|"Y2 f 15" I rpr I T' I T" I ~lT I'TO I ~18 

The milk-teeth are twenty in number; thus, 1 and 2 
are the lower incisors, usually first teeth; then follow 3 
and, 4 upper incisors. 

Normal children usually teeth in pairs, and not 
singly, whereas rachitic children usually have an eruption 
of single teeth, and distinct backwardness in their appear- 

(300) 



DENTITION. 



301 



ance. Milk-teeth remain until a child is a year old, when 
they give place to permanent teeth. 

Baginsky emphasizes the fact that enough stress is 
not laid on the clinical importance of carious teeth as in- 
dicating tuberculosis and scrofulous conditions. In my 
section on treatment of rickets I have mentioned the 
value of a nitrogenous diet, especially proteids (albumi- 
noids), to aid in the formation of bony structures. The 
teeth are also included in this category. 




Fig. 42. — Two Middle Lower Incisors. Three to 10 
Months: Average, 7 Months.*^^ 



Thus, when such drugs as glycerophosphate of lime 
or iron and hygienic measures are indicated for the treat- 
ment of rickets they are of especial value where backward- 
ness in teething exists. 



'^ I am indebted to the kindness of Dr. Dillon Brown for the 
illustrations, which have recently appeared in "The Nursery." 



302 



INFANT-FEEDING. 




Fig. 43. — Nine to 16 Months. Four Upper Incisors. 




Fig. 44. — Two Lateral Lower Incisors and 4 Anterior 
Molars. Thirteen to 17 Months. 



DENTITION 



303 




Fig. 45. — Four Canines. Sixteen to 21 Months. 




Fig. 46. — Twenty- three to 36 Months, although the Average 
is 24 to 30 Months. 



CHAPTEE XLI. 

Athrepsia Infantum. (Maeasmus, or Atrophy; Wast- 
ing Disease, or Malassimilation of Food.)^^ 

If infants, when a few months old, suffer with vomit- 
ing or diarrhoea, and this condition is allowed to become 
chronic, then colic and flatulence, associated with con- 
stipation, supervene, and result in a gastro-intestinal ca- 
tarrh. I^eglect of this condition means the development 
of the condition known as athrepsia. The infant does not 
thrive, commences to Avaste, and, unless we realize the 
condition and give the baby proper treatment, such a 
child will die of exhaustion from inanition. When these 
cases linger for months, they develop rachitis. Recovery 
without treatment is impossible. Parrott was the first to 
define this disease, and classified it into three stages: — 

1. The infant suffers from a simple diarrhoea or 
looseness of the bowels. The stools, instead of being 
bright yellow and homogeneous, are liquid, curdy, often of 
a green color, and contain an excessive quantity of mucus. 
The abdomen is distended with gas and remains con- 
stantly in this condition; the tongue is coated and the 
patches of a stomatitis appear in the mouth. The infant 
is restless, constantly whining, and will not sleep at night. 
The milk, being retained, curdles; the tissues become 
flabby, and w^asting commences. 

2. The symptoms are intensified and the character- 



"^ Presented to the Section on Diseases of Children, at the 
Fifty-first Annual Meeting of the American Medical Association, 
held at Atlantic City, N. J., June 5-8, 1900. 

(304) 



ATHREPSIA INFANTUM. 305 

istic wasting becomes manifest. The stools, for the most 
part, are loose and frequent, and consist of undigested 
food; they are often pale and pntty-like, with a pecul- 
iar odor. At other times they are dark brown, from the 
presence of altered bile. The infant is most voracious, 
liquid food does not seem to satisfy it, and by the mis- 
taken kindness of its friends it is fed with some thick 
food, like soft bread, a diet which has the great advantage, 
in their eyes, of keeping it quiet for a longer time than 
liquid food or diluted milk. At times it can hardly be 
made to sleep, or only dozes for a short time, unless under 
the influence of a soothing-syrup applied by its nurse. 
The mouth becomes the seat of a parasitic stomatitis; 
the skin is harsh and dry; small boils or a lichenous rash 
makes its appearance. The buttocks and genitals are raw 
and excoriated. Its temperature is below normal; the 
feet and hands are congested; the face has a pallid, 
earthy tint; and a sickly lactic-acid smell is given out 
from the body, especially the abdomen. The wasting is 
extreme, the face being shriveled, the skin wrinkled and 
hanging in folds about the thighs and arms. 

3. The third stage brings the child into a moribund 
state. It is too feeble to cry, becomes heavy and drowsy, 
taking little notice of anything. Death then ensues, prob- 
ably preceded by a muscular twitching, strabismus, or gen- 
eral convulsions. 

Henoch does not like the term "athrepsia,^^ intro- 
duced by ParrOtt, but prefers "atrophy." The first symp- 
tom that this author noticed is that the chikVs weight 
does not increase; and hence he emphasizes the impor- 
tance of frequently weighing children. He regards the 
weight taken once a week as sufficient, so that it can be 
a determining factor as to the progress made by an infant. 



30() INFANT-FEEDING. 

Henoc']i says that at the end of the first month the weight 
is increased one-third, at the end of the fifth month it is 
double, and at the end of the twelfth month it should be 
three times the weight at birth. Weaning, dentition, and 
all other pathological conditions interfere with a proper 
increase in weight. 

By far the greatest number of cases of athrepsia are 
found in bottle-fed children. There are, however, a great 
many cases to be seen among breast-fed children. We 
can then be positive that the breast-milk is lacking in 
some of its chemical constituents, and frequently we find 
that it is the proteids that are deficient in quantity. If, 
therefore, we meet with a case of athrepsia in a breast-fed 
child, the thing to do is to have a chemical examination 
made of the breast-milk. If the latter is found deficient 
in quality, then we must withdraw it. 

A great many children will be found to thrive at once 
after having been removed from the breasts and changed 
to some artificial mode of feeding, whereas the reverse is 
also true. If, therefore, we wish to do away with its own 
mother's milk, for some positive reason, it is advisable to 
secure a wet-nurse having a child as near the age of the 
one she is to suckle as possible. The hereditary history 
of a nurse is of great importance, as is also-the quantity 
and quality of her milk, which should be thoroughly ex- 
amined before she is given this foster-child. 

The treatment of this disease is one which resolves 
itself into removing the cause, and if bad hygienic sur- 
roundings — as impure air, crowded apartments, and im- 
proper diet — are the cause, then these must be remedied 
at once. Medication amounts to nothing in the treatment 
of this disease. 

With hand-fed or bottle-ferl children we can easily 




Vv^. 47. — Allno])sia Tiifantuiii. 



ATHREPSIA INFANTUM. 307 

regulate the condition of their bowels, and also easily 
regulate the quality and quantity of the food given them. 
The blandest and least irritating food must be selected, 
while frequent weighing of the infants should be resorted 
to in order to ascertain the progress that is being made. 

Where there is much diarrhcea, milk must be used 
sparingly or altogether omitted for awhile, as the hard 
curds formed in the stomach are beyond the weak di- 
gestive powers of the weakened stomach and intestines. 
Small quantities of whey and barley-water, white of egg 
and barley-water, or the juice of a rare chop or steak may 
be given at short intervals during the day and night. 

As soon as the child improves in respect to the diar- 
rhoea, milk in some form may be allowed. Peptonized 
milk is often of much value in these diseases when made 
by mixing 3 ounces of cold milk, adding 2 teaspoonfuls of 
cream, with ^/.^ of a peptonizing powder, and given to the 
infant after it has stood for fifteen minutes. 

The cream-mixtures are often of much service, such 
as 1 ounce of cream, 3 ounces of barley-water, and 1 tea- 
spoonful of sugar. Every care must be taken that the 
feeding-bottle is clean, and the food prepared with the 
most'scrupulous neatness. 

The great difference between cows' milk and human 
milk is the fact that human milk is persistently alkaline, 
whereas cows' milk is usually acid: that there is more 
nitrogenous material in cows" milk: that there is a much 
smaller percentage of milk-sugar in cows' milk, and, 
finally, that the nitrogenous constituents of the milk of 
the cow are affected by rennet in a manner different from 
those of mothers' milk. 

In order, therefore, to feed cows' milk to infants, 
these differences must be corrected, and the correction 



308 INFANT-FEEDING. 

of them causes further differences, which have, ill turn, 
also to be corrected; the process, therefore, is a com- 
plicated one. 

Before considering the means adopted to alter the 
chemical composition of cows" milk, it would be proper 
to state that there is a common, but false, belief that milk 
from one cow is the best for infants' use. The principle 
that underlies this belief is perfectly right. It is, that it 
is desirable to obtain milk of uniform composition; but 
it has been found experimentally that milk of the same 
cow varies in its composition during twenty-four hours, 
and that it is, in reality, more likely that a mixture of 
the milk from several cows will show a more constant 
analytical result than that from one single animal. Jacobi 
and others have stated that the chances of infection from 
tuberculosis through the medium of milk can only be less- 
ened by feeding from a large number of cows. 

In order to render the character of cows' milk similar 
to that of human milk, it is necessary to reduce the 
amount of casein in cows' milk. This is usually done by 
treating the milk with water, thus diluting it; but some- 
times lime-water is used, for the reason to be stated im- 
mediately. 

Second, the proportion of fat in cows' milk is less 
than in human milk, and it has been still further reduced 
by dilution. Therefore, it is necessary to add to it fat in 
some form or other, and this is commonly done by adding 
cream. 

Thirdly, sugar must be added to cows' milk in order 
to bring the lactose up to the proper level. It has been 
held by some that it is necessary to use milk-sugar for 
this purpose, but there seems to be little doubt that cane- 
sugar will serve the purpose quite well, or even better. 




Fio-. 4S. — Atliiepsia [iifanliini. 



ATHREPSIA INFANTUM. 309 

In the fourth place^ according to Jacobi^ it is neces- 
sar}' to prevent as far as possible the great coagulating 
effect that the ferment of the infants' gastric juice has 
on the casein of cows' milk^ and this is satisfactorily ac- 
complished by adding an alkali, such as lime-water, or 
some mucilaginous material, such as barley-water. In 
this way* the casein curd is rendered loose and JBLocculent 
and more like that of human milk. 

Dr. Meigs, of Philadelphia, advises the preparation 
of the following mixture: Cream, 2 ounces; milk, 1 ounce; 
lime-water, 2 ounces; sugar-water, 3 ounces; the latter 
is made by dissolving about 2 ^ / ^ ounces of milk-sugar in 
a pint of water. 

Condensed cows^ milk is simply cows' milk that has 
been evaporated to one-fourth of its volume and sterilized. 
nothing at all being added to it. Then, again, there is a 
form in which the milk is not only condensed, but has 
also the addition made to it of about 50 per cent, of cane- 
sugar. When it is also borne in mind that the composi- 
tion of condensed milk varies with the season of the year, 
great fluctuations must occur in its chemical constitution. 

Condensed milk must also- be diluted with water be- 
fore it is fit for use, and this dilution may entirely dis- 
arrange the proportion of the component parts of the 
fluid. For this reason it is found that even where infants 
appear to thrive on condensed milk, their apparent good 
health is due to an excessive deposit of fat, and not to a 
suflicient supply of albuminoids; and they are, in the 
long run, more prone to disease than babies fed on the 
breast or on cows' milk properly prepared. 

The above remarks apply with less force to that va- 
riety of condensed milk which is made from sterilized 
fluid and then sweetened; but even this preparation re- 



310 INFANT-FEEDING. 

quires for digestibility to be diluted some ten times, and 
this reduces its nutritive value to a dangerous degree. 

At times we must resort to various methods of feed- 
ijig, until we find the method on which a bab}^ will thrive, 
and so it is that we have: (1) humanized milk, (2) steril- 
ized milk, (3) pasteurized milk, and (4) peptonized milk. 

1. Humanized milk is simply cows' milk diluted with 
a certain amount of whey and with some cream. It is 
prepared in the follow^ing way: A pint of milk is set aside 
in a cool place until the cream rises to the surface. This 
is skimmed oft' and kept, and to the milk remaining is 
added enough rennet to curdle it thoroughly. The whey 
is strained oft: from the curd and added with the cream, 
previously separated, to a pint of fresh cows' milk, and the 
mixture is known as humanized milk. It is distinctly 
more digestible than ordinary diluted milk, and often 
agrees well with young infants, being given without any 
further dilution, in quantities suitable to the age of the 
infant. It may be employed exclusively during the first 
three months of the infant's life, and after that age may 
be used in combination with some farinaceous food. 

2. Sterilized milk is that in which all germs tending 
to decompose it have been destroyed by exposure to a 
boiling heat at a temperature of 212° F. for a short period 
of time: from 15 to 45 minutes. Fresh cows' milk always 
contains impurities received from the cow or the at- 
mosphere or from the vessels in which it is contained, 
though much care may have been taken to maintain abso- 
lute cleanliness. The milk is usually exposed to the ac- 
tion of steam or in a boiling heat from 5 to 45 minutes, 
and will keep about 24 hours. A fresh bottle must always 
be opened for each meal; if anything is left in the bottle 
after the baby has finished, it must be thrown out. 



ATHKEPSIA INFANTUM. 311 

3. Pasteurized milk is simply steamed at a tempera- 
te 170°, for about 30 minutes; in other 
words, it is really sterilized milk at a lower temperature. 

-1. Peptonized milk, the fourth substitute for ordi- 
nary diluted milk, is as simple a preparation as sterilized 
milk. It consists of milk which has previously been par- 
tially digested by the addition of some preparation of a 
digestive ferment, among the best known of which are 
Benger's liquor pancreaticus, Fairchild's peptonizing pow- 
ders, etc. The milk should be diluted to some extent be- 
fore being peptonized; but it is not necessary to dilute 
to such an extent as has been recommended for ordinary 
cows^ milk. Generally, even for an infant two or three 
days old, the addition of an even quantity of barley-water 
will be sufficient, and, when a baby is two or three months 
old, a dilution of 2 parts of milk with 1 part of water will 
be digested with comfort. 

In France there is a law forbidding anyone to give 
solid *food of any kind to infants under a year without 
the written authority of a qualified medical man. 

Jacobi says: "Whatever I have here brought forward 
is certainly not to disparage the boiling of the milk; it 
is to prove the danger of relying on a single preventive 
when the causes of intestinal disorders are so many."" it 
is true, however, that the large majority of the latter de- 
pends on causes which may be met by sterilization; but 
not by sterilization only; also by pasteurization, that is, 
heating the milk to 70° C. (165° F.), and keeping it at 
that uniform temperature for 30 minutes: a procedure 
which destroys the same germs that are killed by a more 
elevated temperature, without much change in flavor and 
taste. 

One of the questions connected with the employment 



ol2 ijNl^ANT-EEEDING. 

of sterilized or pasteurized milk is this: whether the 
milk to be used for a child ought to be prepared at home, 
or whether the supply may be procured from an estab- 
lishment where large quantities of milk believed to be- 
come immutable by sterilization for an indefinite period 
are kept for sale. In regard to this problem Fltigge 
plainly expresses his regrets that ''we have allowed our- 
selves to be guided by people who are neither hygienists 
nor physicians, but chemists, farmers, or apothecaries, 
and whose actions have been based on three false beliefs. 
Of these the first is that boiling for three-quarters of an 
hour destroys germs; the second that whatever bacteria 
remain undestroyed are innocuous, and the third, that 
proliferating bacteria can always be recognized by 
symptoms of decomposition." Nothing is more erro- 
neous. Soxhlet himself, the German originator of 
sterilization, knew at an early time that the ferment- 
ing process is now and then but partially interrupted 
by boiling, that butyric acid may be found in plgce of 
lactic acid, that a strong evolution of gas may be caused 
after much boiling, and that such milk may give rise to 
flatulency. Aye, milk which happens to contain the re- 
sistant spores of bacteria becomes a better breeding- 
ground for them by the very elimination of lactic acid, 
and the longer such sterilized milk is preserved and 
offered for sale, the worse is its condition. It may be true 
that these conditions are not met with very frequently, 
but an occasional single death in a family caused by 
poisonous milk will be more than enough. Therefore, the 
daily home-sterilization is by far preferable to the risky 
purchase from wholesale manufacturers who cannot guar- 
antee, because, in the nature of things, they cannot know 
the condition of their wares. 



ATHREPSIA INFANTUM. 313 

Another alteration of a less dangerous character, but 
far from being desirable^ is the separation of cream from 
sterilized milk which is preserved for sale. Renk'^ found 
it to take place to a slight extent during the very first 
weeks, but later to such a degree that 43.5 per cent, of all 
the cream contained in the milk was eliminated. 

Sterilization has been claimed to be no unmixed boom 
because of its changing the chemical constitution of milk. 
Still, the opinions on that subject vary to a great extent, 
the occurrence of changes being both asserted and denied 
by apparently competent judges. But what I have said 
a hundred times is still true and borne out by facts, viz. : 
that no matter how beneficial boiling, or sterilization, or 
pasteurization may be, they cannot transform cows' milk 
into woman's milk, and that it is a mistake to believe that 
the former, by mere sterilization, is a full substitute for 
the latter. It is true, that when we cannot have woman's 
milk we cannot do without cows' milk. There is no 
alleged substitute that can be had with equal facility or 
in sufficient quantity. But after all it is not woman's 
milk. Babies may not succumb from using it, and may 
seldom appear to suffer from it; indeed, they will mostly 
appear to thrive on it, but it is a make-shift after all, and 
requires modifications. Hammarsten was the first to 
prove the chemical difference between the casein of cows' 
and woman's milk. Whatever was known on that subject 
at that time I collated in Gerhardt's "Handbuch der 
Kind," vol. i, 1875 (second edition, 1882). But lately 
Wroblewski demonstrated the difference in solubility of 
the two milks. Woman's casein retains, during pepsin di- 
gestion, its nuclein — proteid rich in phosphorus — in solu- 



Archiv fiir Hygiene, xvii. 



314 INFANT-FEEDING. 

tion^ which is fully digested; in cows' casein the nuclein is 
not fully digested^ — a "paranuclein'' is deposited undis- 
solved and undigested. 

Henry A. Bunker, in an article on the modification 
of cows' milk, says that the difficulty of the digestion of 
the casein of cows' milk in some children has seemed to be 
the resistance to the infant's digestive powers, even after 
the partial hydration supposed to be brought about by 
hydrochloric acid and heat. In all such cases the faecal 
evacuations were white, hard, and dry, such as so often 
occur on a plain, sterilized-milk diet. In many of these 
cases, these dry, scybalous masses would frequently set up 
mucous diarrhoea and give rise to severe colicky pains. 

The only evidence of partial hydration by the acid 
and heat would seem to be the fact of increased nutrition 
in spite of these difficulties. Professor Chittenden'^ 
maintains and proves, by a beautiful laboratory-experi- 
ment, that the products of gastric digestion have the 
power of combining with more hydrochloric acid than the 
original proteid, for, as soon as proteolysis commences, the 
products so formed begin to show their greater affinity for 
acid by withdrawing acid from its combination with the 
native proteid: a supposition which is necessary to account 
for even the starting of the proteolytic process. Further, 
it is evident that proteoses and peptones combine with a 
far larger equivalent of acid than the native proteid- 
albumin, in the experiment, is capable of. This, doubtless, 
depends upon the cleavage of the large proteid molecule 
into a number of smaller or simpler molecules, each of the 
latter, j)erhaps, combining with a like number of hydro- 
chloric-acid molecules. However this may be, it is evi- 



'Cartwright Lectures on Digestive Proteolysis," 1894. 



ATHREPSIA INFANTUM. 315 

dent that the products of pepsin-proteolysis combine with 
a larger amount of hydrochloric acid than the mother- 
proteid^ and that the transformation of the latter, at least 
under the conditions of the experiment, is a slow and 
gradual process. 

It will be remembered that the original method pro- 
posed the hydration of the milk-proteids by hydrochloric 
acid and a rather prolonged boiling. Twenty drops of a 
10-per-cent. hydrochloric-acid solution were added to 1 
pint of water and 1 quart of milk, and this mixture was to 
be kept at boiling temperature for about twenty minutes. 
The addition of a larger amount of the acid, unless the 
milk was quite fresh, was found to result quite frequently 
in curdling the milk. It was also found that the acid so 
added, up to the poini of saturation or breaking, exists 
as combined acid, as was evident from the failure of re- 
agents to show free hydrochloric acid in the completed 
mixture. 

The indications that the hydration secured by this 
method is not always sufficient to meet the requirements 
of certain infantile stomachs and the fact that usually in 
such cases the nutrition is increased in spite of incomplete 
and painful digestion, seemed so strongly confirmatory 
of the results of Professor Chittenden's researches, that I 
determined to copy, in part, his experiments on HCl 
saturation, as applied to the proteids of milk. 

To this end, milk was prepared in the original way, 
except that the 20 drops of dilute hydrochloric acid were 
added in ^7^, instead of 1, pint, watery solution, and 
slowly, but intimately, mixed with 1 quart of milk. This 
mixture was brought as rapidly as possible to the boiling 
temperature and then set aside until another half-pint of 
water was prepared with 20 drops more of the acid. This 



316 INFANT-FEEDING. 

was added to the previously-boiled milk and acid, stirred 
thoroughly, and again brought to the boiling-point. The 
result thus obtained was a thoroughly palatable milk, with 
no taste of having been boiled, and gave no indication of 
free hydrochloric acid with Gunzberg's reagent. Kudisch's 
plan is similar to the latter. 

Proteids in excess are indicated by the presence of 
curds in the stools. This is the most frequent cause of 
colic in infants. Sometimes there is diarrhoea, more often 
constipation when the proteids are in excess. The excess 
of proteids frequently causes vomiting and so does an 
excess of both fat or sugar. If, therefore, after reducing 
the percentage of proteids, fat, or sugar, vomiting still 
persists, then we must feed the baby with smaller quanti- 
ties. Thus, we may have to give a 4-ounce bottle where a 
6-ounce or a 5-ounce feeding causes vomiting. Certain 
rules can be laid down: if an infant does not thrive, — that 
is, does not gain in weight without showing any signs of 
indigestion, — then the proportions^ — i.e., percentages of 
all ingredients — should be gradually increased; chiefly the 
proteids, however, for the latter is the most important 
element in an infantas food. 

An infant soon after birth was put on modified milk, 
containing: — ■ 

Fat 2.00 

Milk-sugar 5.00 

Albuminoids 0.75 

Lime-water ^/ic 

I ordered eight feedings, 2 ounces in each. As the 
child was constipated, soon after we increased the for- 
mula to the following percentages: — 



ATHEEPSIA INFANTUM. 317 

Fat 2.50 

Milk-sugar 6.00 

Albuminoids 1.00 

Lime-water . ^/is 

As the stools did not change, the fat was increased 
to 3 per cent., other ingredients the same. The child 
gained but 3 onnces in weight in five weeks; had greenish, 
curded stools, and had distinct evidence of intestinal indi- 
gestion. It also vomited curds. The general condition of 
the child was one of extreme irritability, with very little 
sleep. Hand-feeding was stopped. The child's ali- 
mentary tract was thoroughly cleaned, and a wet-nurse 
secured. This was when the baby was six weeks old; the 
child nursed well, gained 6 ounces the first week, 8 ounces 
the second, and weighed 14 pounds when it was four and 
a half months old. The child improved until it was seven 
months old, when suddenly the weight remained station- 
ary. A specimen of breast-milk was sent to John S. Adri- 
ance, the chemist of the Nursery and Child's Hospital, 
who found the following percentages:— 

Fat ;. .2.000 

Sugar 7.431 

Proteids 0.882 

Ash 0.162 

Specific gravity, 1031; reaction, alkaline. 

It is very evident that the deficiency in albuminoids 
or proteids is accountable for the stationary weight. The 
child did not gain an ounce in one month. We discharged 
the wet-nurse, and resorted to hand-feeding, when the 
child's general condition changed, and she is bright and 
well to-day. 

In another instance, a child had been nursed by its 
own mother for three months, and had gained in weight 



318 INFANT-FEEDING. 

regularly at the rate of 6 and 7 ounces per week; the 
stools were normal in quantity and quality, when sud- 
denly the child appeared to be colicky, was restless at 
night, had green stools, and did not appear to thrive. For 
two consecutive weeks the child did not gain in weight, 
and a specimen of breast-milk was sent to the Pediatrics 
Laboratory. Mr. E. W. Bailey, the chemist, examined 
the specimen, with the following result:— 

Fat 2.43 

Proteids 1.25 

Sugar 6.51 

Ash ' 0.20 

Total solids 10.39 

Specific gi'avity, 1027; reaction, slightly alkaline. 

The percentage of fat and proteids is so low that it 
was very plain to me why this child did not increase in 
weight. On putting the child on an oatmeal and top-milk 
mixture, the digestion improved, the child^s sleep was 
better, and the weight increased. 

Another ease was that 'of a nursling, brought to me 
with a history of excessive crying, greenish stools, cheesy 
curd in the stools, vomiting, restlessness, and a general 
condition of malassimilation; I asked for a specimen of 
breast-milk, which Mr. Bailey kindly examined, with the 
following result: — 

Fat 4.32 

Sugar 6.22 

Proteids 1.80 

Ash 0.19 

Total solids 12.53 

Konction, neutral. 



ATHEEPSIA INFANTUM. 319 

The general history of the case showed that the child 
was fed every time it cried^ and thus it was evident that 
overfeeding was the real cause of the trouble in this case, 
for I learned that the child frequently nursed for hours 
at the breast, and was also allowed to go to sleep with the 
nipple in its mouth. Whenever the child cried it was fed, 
frequently as often as every half-hour, so that in this case, 
while the quality of the breast-milk was absolutely nor- 
mal, as demonstrated by the chemical examination, it re- 
quired only the judicious interval for feeding to give the 
child^s stomach proper time for the assimilation of its 
food. 



CHAPTEK XLII. 

(tEneral Rules foe Rectal Feeding. 

In another chapter entitled "Rectal Feeding in Diph- 
theria" attention has already been given to the method 




Fig. 49.— Author's Double -Current Rectal Tube for Flushing 
the Colon and Rectum and Used for Rectal Feeding. 




Fig. 50. — Rectal Syringe. 

of cleansing the rectum, and also to the injection of foods. 
The same rules are applicable when there is excessive 
(320) 



GENERAL RULES FOR RECTAL FEEDING. 



321 



irritability of the stomach with constant vomiting and 
where it is desirable to o-ive the stomach absolute rest. 




Fig. 51. — Rectal Syinnge. 



Small quantities properly injected will be retained and 
absorbed much easier than large quantities of food^ which 
will merely serve as irritants and be expelled. 



CHAPTEE XLIII. 

Nasal Feeding. 

Nasal feeding has long been in nse where diseases of 
the mouth or spasm of the jaw or intubation in diphtheria 
rendered swallowing difficult. A thin rubber catheter is 




Fig. 52. — Author's Apparatus for Irrigating Rectum and well 
Adapted for Stomach- washing (Lavage) and also for 
Forced Feeding (So-Called Gavage). Also Useful in Nasal 
Feeding. 

attached to a long rubber tube ending in a funnel, which 
is the same apparatus as has been already described on 
(322) 



NASAL FEEDING. 323 

page 244: in tlie chapter on '"'•Stoniacli- washing and Gav- 
age/' 

Modus Operandi. — Lay the child flat on its back and 
have a large sheet pinned over the body, so that the hands 
are firmly held; have the feeding-mixture all prepared, 
so that no time will bo lost. A soft-rnbber catheter, kibri- 
cated with vaselin or glycerin, is gently pushed into the 
nostril and glided through the pharynx into the oesopha- 
gus and stomach. When the tube is in the stomach, pour 
the required amount of food into the funnel so that it 
flows in the stomach. When the proper amount has been 
used, withdraw the catheter from the nose, and boil it in 
warm water to properly sterilize it for the next feeding. 

Quantity of Food. — The quantity of food used in 
nasal feeding should be somewhat less than is ordinarily 
used in health. It is understood that only liquid foods 
— like peptonized milk, sterilized milk, soups, broths, 
or bouillon — can be used for feeding in this manner. A 
thin emulsion of egg can also be used. Owing to the fre- 
quency of both nausea and vomiting, which may be in- 
duced by irritation of the fauces, while the tube is gliding 
through the pharynx into the oesophagus, a much larger 
interval must be given between the feedings. It is de- 
sirable to introduce the tube rapidly and remove it 
rapidly if it is at all possible. Accidents will result in 
nasal feeding if a large quantity of liquid food is regurgi- 
tated through the oesophagus into the mouth and aspirated 
through the larynx into the trachea. Many a case of 
'^Sclikich-pnenmonie'' can be traced to accidents of this 
kind. 



DIETAEY. 

Almond-milk. 

Take 2 ounces of sweet almonds^ scald them with 
boiling water; after a few moments express them from 
the hulls; then pour the hot water away. Put the 
blanched almonds into a mortar and pound them thor- 
oughly, and add either 2 ounces of milk or 2 ounces of 
plain water. After this is thoroughly mixed, it is to be 
strained through cheese-cloth, and the strained liquid will 
be the almond-milk. 

Keller's Malt-soup. 

Take of wheat-Hour 50.0 (about 2 ounces). To this 
and 11 ounces of milk. Soak the wheat-Hour thoroughly, 
and rub it through a sieve or strainer. 

Put into a second dish 20 ounces of water, to which 
add 3 ounces of malt-extract; dissolve the above at a tem- 
perature of about 120° F., and then add 10 cubic centi- 
metres (about 2 Y^ drachms) of 11-per-eent. kali-carbonic 
solution. Finally mix all of the above ingredients, and 
boil. 

This gives a food containing: — 

Albuminoids 2.0 per cent. 

Fat 1.2 per cent. 

Carbohydrates 12.1 per cent. 

There are in this mixture: — 

Vegetable proteids 0.9 per cent. 

The wheat-flour is necessary, as otherwise the malt- 
soup would have a diarrhoeal tendency. The alkali is 
(324) 



DIETARY. 325 

added to neutralize the large amount of acid generated in 
sick children. Biedert emphasizes the importance of giv- 
ing fat, rather than reducing its quantity, in poorly- 
nourished children, and cites the assimilability of his 
cream-mixture or of breast-milk in under-fed children as 
proof of his assertions. The author has used this malt- 
soup most successfully in the treatment of athrepsia 
(marasmus) cases in which the children were simply 
starved. 

Junket of Milk and Egg. 

Beat 1 egg to a froth and sweeten with 2 teaspoonfuls 
of white sugar. Add this to ^/o pint of warm milk; then 
add 1 teaspoonful of essence of pepsin (Fairchild); let it 
stand till it is curdled. The above is useful in .typhoid 
and similar wasting diseases. 

Plain Junket. — This is sometimes called ''curds and 
whey.^' Take ^/^ pint of fresh, raw milk, and heat it luke- 
warm. Then add a teaspoonful of Fairchild's essence of 
pepsin, and stir the mixture thoroughly. Pour into cus- 
tard cups, and let it stand until firmly curdled. The flavor 
can be improved by adding some essence of lemon or 
cinnamon or grated nutmeg. 

When the essence of pepsin (Fairchild^s) cannot be 
had, or for convenience in traveling, the author has used 
Hansen^s junket tablets, which will give similar results 
as with the liquid essence of pepsin. 

Peptogenic Milk-powder. 

The pancreas ferment trypsin is known to have a re- 
markable affinity toward milk, digesting its casein with 
great rapidity without altering its other elements, and 
without rendering the milk repulsive. When milk is so 



I 



326 INFANT-FEEDING. 

treated it is known as peptonized milk. Through the ex- 
pert investigation of the well-known chemist, Dr. Albert 
Leeds, the peptogenic milk-powder was found to yield a 
milk which was similar to a hnmanized milk. The author 
has had some experience in the modification of cows' milk 
by the addition of peptogenic milk-powder, and can safely 
say that it is one of the most valuable additions to our 
infant-feeding that we possess. 

There are three steps necessary for the preparation 
of "humanized milk" in using the peptogenic milk- 
powder: — 

1. To prepare — with peptogenic powder, cows' milk, 
water, and cream — a mixture which has the quantitative 
composition of average human normal milk. 

2. To subject this mixture to the action 'of the di- 
gestive principle by which the albuminoids (casein, etc.) 
are converted into such form as to become identical with 
those of human milk. 

3. To then destroy the digestive ferment by simply 
raising the temperature of the milk to the boiling-point. 
This heat also destroys the bacteria, and renders the milk 
practically sterile during the time required for its use: 
twentv-four hours. 



No. 1. — For the daily food of a healthy infa^it: Put 
into a clean graniteware or porcelain-lined saucepan one 
measure (which accompanies each bottle) of peptogenic 
powder; add to this ^/2 pint of cold water, ^/o pint of cold, 
fresh milk, and 4 tablespoonfuls of cream. Place the 
saucepan on a hot range or gas-stove, and heat, with 
constant stirring, until the mixture boils. The heat should 
he so applied as to make the milk hoU in ten minutes. Keep 



DIETARY. 327 

in a clean^ well-corked bottle, in a cool place. AVhen 
needed^ shake the bottle, and pour out the desired por- 
tion, and warm the same before feeding. 

No. 2. — Specially designed for children with feeble 
digestion, or when the stomach and bowels are disordered, 
as in catarrhal conditions. Put into a clean bottle 1 meas- 
ure of the peptogenic powder, Vo pint of cold water, ^/^ 
pint of cold, fresh milk, and 4 tablespoonfuls of cream. 
Shake well, place the bottle in a pail or tin kettle of water, 
holding a gallon, as hot as can be borne by the hand 
(115° F.), and keep the bottle there for thirty minutes. 
Then pour all into a saucepan, and quickly heat to boiling- 
point, with constant stirring. The bottles of the peptog- 
enic milk-powder made by Fairchild Brothers & Foster 
have a metal screw-cap, which is the measure above al- 
luded to. If the infantas digestive powers are still weaker, 
or if, after feeding the last-named formulse, vomiting 
takes place, then it is safer to use: — 

One measure of peptogenic milk-powder. 
One-third pint of raw milk. 
Two-thirds pint of water. 

Mix, heat, and boil, as described above, and it is ad- 
visable to feed at longer intervals; for example, every 
three or four hours, if the infant has previously been fed 
every two or three hours. Never use the balance left over 
in a feeding-bottle, after the infant has sucked, but al- 
ways give a fresh quantity of food for each meal, and 
whatever the baby leaves should be invariably thrown 
away. 

The weight and the stools are important factors in 
judging when to increase the quantity of milk and cream, 
or rice versa. 



328 infant-feeding. 

Peptonized Milk. 

Into a clean, quart bottle put the powder contained 
in one of the Fairchild peptonizing tubeS;, and a teacnpful 
(gill) of cold water; shake, then add a pint of fresh, cold 
milk, and shake the mixture again. Place the bottle in 
water so hot that the whole hand can be held in it without 
discomfort. (About 115° F.) 

Keep the bottle there five or ten minutes as directed. 

At the end of that time put the bottle on ice at once 
to check further digestion and keep the milk from spoil- 
ing. 

Place the bottle directly in contact with the ice. 

The degree of digestion is very simply regulated by 
the length of time in which the milk is kept warm. 

partially peptonized milk. 

Put into a clean agateware or porcelain-lined sauce- 
pan the powder contained in one of the Fairchild pep- 
tonizing tubes, and a teacupful (gill) of cold water; stir 
well; then add a pint of cold, fresh milk. Heat with con- 
stant stirring until the mixture boils. The heat should 
be so applied that the milk will come to a boil in ten min- 
utes. When cool, strain into a clean bottle, cork well, and 
keep in a cold place. When needed, shake the bottle, 
pour out the required portion, and serve cold or hot, as 
directed by the physician in charge. Milk so prepared 
will not become bitter. 

immediate process. 
Put 2 tablespoonfuls (1 ounce) of cold water in a gob- 
let or glass; dissolve in this one-quarter the contents of a 
peptonizing tube; add 8 tablespoonfuls (4 ounces) of 
warm milk; drink immediately, sipping slowly. 



DIETAKY. 329 

If half a pint of milk is required, double the propor- 
tions of water, peptonizing powder, and milk. 

COLD PROCESS. 

Into a clean, quart bottle put the powder contained 
in 1 of the Fairchild peptonizing tubes, and a teacupful 
(gill) of cold water; shake, then add a pint of fresh, cold 
milk; shake the mixture again and immediately place the 
bottle on ice, without subjecting it to the water-bath or 
any heat. Place the bottle directly in contact with the 
ice. 

When needed, shake the bottle, pour out the required 
portion, and use in the same manner as ordinary milk. 

Peptonized Milk-geuel. 

Thick, well-boiled, hot gruel ^A pint. 

Milk, fresh, cold ^/a pint. 

Mix and strain into a small pitcher or jar, and im- 
mediately add the contents of 1 Fairchild peptonizing 
tube: mix well. Let it stand in the hot water-bath, or 
warm place, for five minutes, then put in a clean bottle 
and place on ice. Serve hot or cold. 

Gruel made from arrowroot, flour, barley, oatmeal, 
etc., will serve for the purpose. In each instance the fari- 
naceous material should be boiled with water until the 
starch-granules have been thoroughly swollen, broken up, 
and incorporated with the water. 

Junket (Curds and Whey). 

Junket. — Take ^/^ pint of fresh milk, heated luke- 
warm — not warmer than can be agreeably borne by the 
mouth (about 115° F.); add 1 teaspoonful of Fairchild's 
essence of pepsin, and stir just enough to mix. Pour into 



330 INFANT-FEEDING. 

custard-cups; let it stand until firmly curdled; may be 
served plain or with sugar and grated nutmeg. 

An egg beaten to a froth and sweetened with 2 tea- 
spoonfuls of sugar may previously be added to the half- 
l^int of milk^ forming a highly nutritious and smooth jelly. 
The essence will curdle milk with egg as readily as plain 
milk. 

^yhey. — Curdle warm milk with the essence of pepsin 
as above directed; then beat u^o with a fork until the curd 
is finely divided; now strain, and the whey is ready for 
use. 

Whey is a highly-nutritious fluid food peculiarly use- 
ful in many ailments and ahvays valuable as a means of 
variety in diet for the sick. It is frequently resorted to as 
a food for infants to tide over periods of indigestion, sum- 
mer complaints, etc. 

Gum-Aeabic Watee. 

Dissolve 1 ounce of gum arable in a pint of boiling 
water; add 2 tablespoonfuls of sugar, a wineglassful of 
sherry, and the juice of a large lemon. Cool and add ice. 

LiME-WATEE. 

Pour 2 quarts of water over fresh unslaked lime the 
size of a walnut; stir until slaked, and let stand until 
clear; then bottle. Lime-water is often ordered with 
milk to neutralize acidity of the stomach. 

Tamaeind-watee. 

A very refreshing drink may be made by adding 1 
pint of hot water to 1 tablespoonful of preserved tama- 
rinds, and setting aside to cool. 



DIETARY. 331 

Lemonade. 
Squeeze the juice from 1 lemon. Add 2 tablespoon- 
fuls of sugar and 1 cup of water. Strain and serve. 

Milk and Albumin. 
Put into a clean quart bottle 1 pint of milk, the 
whites of 2 eggs, and a small pinch of salt. Cork and 
shake hard for fiye minutes. 

Milk-punch. 

Take V- pii^^ of fresh, cold milk and add 2 teaspoon- 
fuls of sugar, and stir well until dissolved; then add 1 
ounce of either brandy or sherry-wine. 

Orangeade. 
Substitute orange-juice for that of lemon in the 
recipe for "Lemonade.'" 

Tea. 
Scald out the teapot and put in the tea, using 1 tea- 
spoonful for 1 cupful. Pour on toiling water, and let tea- 
pot stand four or five minutes. If allowed to stand too 
long, the tannin in the tea is developed, which not only 
darkens the tea, but also renders it hurtful. 

Albumin- WATER. 
Stir the whites of 2 eggs into ^/^ pint of ice-water, 
without beating; add enough salt or sugar to make it 
palatable. 

Apple-water. 
Slice into a pitcher ^/^ dozen juicy sour applies; add 
1 tablespoonful of sugar, and pour over them 1 quart of 
boiling water. Cover closely until cold; then strain. 



332 infant-feeding. 

Barley-watek. 

Wash 2 ounces (wineglassfiil) of pearl barley with 
cold water. Boil it five minutes in fresh water; throw 
both waters away. Pour on 2 quarts of boiling water; 
boil down to 1 quart. Flavor with thinly-cut lemon-rind; 
add sugar to taste. Do not strain unless at the patient's 
request. 

Cocoa. 

Allow 1 teaspoonful of cocoa for each cup; add suffi- 
cient hot water to form a paste; pour on boiling milk (or 
milk and water) and sweeten to taste; five minutes' boil- 
ing will improve the cocoa. 

Coffee (French). 

Some persons prefer filtered to boiled coffee. Fil- 
tered coffee is best made in a French biggin^ consisting 
of two tin vessels^ one fitting into the other, the upper one 
being supplied with strainers. The coffee, being very 
finely ground, is placed in this utensil, and the boiling 
water allowed to slowly percolate through it. The pot 
should be set where it will keep hot, but not boil, until 
the water has gone through. Pouring it through the cof- 
fee a second time will make it stronger, but it loses in 
flavor. Cafe noir is always made in this way. 

Nutritious Coffee. 

Dissolve a little isinglass or gelatin (Knox) in water; 
put ^/o ounce of freshly-ground coffee into a saucepan 
with 1 pint of new milk, which should be nearly boiling 
before the coffee is added; boil both together for three 
minutes; clear it by pouring some of it into a cup and 
dashing it back again; add the isinglass, and leave the 



DIETARY. 333 

coffee on the back part of the range for a few minutes 
to settle. Beat np 1 egg in a breakfastciip, and npon it 
ponr the coffee; if preferred, drink withont the egg. 

ECtGI^OG. 

Scald some milk by pntting it, contained in a jng, 
into a saucepan of boiling water, tvt do not alloiu the miJh 
to hoil. When cold, beat np a fresh egg with a fork in 
a tnmbler with some sugar; beat to a froth, add a dessert- 
spoonful of brandy, and fill up tumbler with the scalded 
milk. 

Soft Custard. 

Take of corn-starch 2 tablespoonfuls to 1 quart of 
milk; mix the corn-starch with a small quantity of the 
milk, and flavor; beat up 2 eggs. Heat the remainder of 
the milk to near boiling; then add the mixed corn, the 
eggs, 4 tablespoonfuls of sugar, a little Initter, and salt. 
Boil the custard two minutes, stirrijig briskly. 

Calf^s-Foot Jelly. 
Thoroughly clean 2 feet of a calf, cut into pieces, and 
stew in 2 quarts of water until reduced to 1 quart; when 
cold, take off the fat and separate the jelly from the sedi- 
ment. Then put the jelly into a saucepan, with white 
wine and brandy and flavoring to taste, with the shells and 
whites of 4 eggs well mixed together; boil for a quarter 
of an hour, cover it, and let it stand for a short time, and 
strain while hot through a flannel bag into a mold. 

Tapioca-cream. 
Take 1 pint of milk, 2 tablespoonfuls of tapioca, 2 
tablespoonfuls of sugar, 1 saltspoonful of salt, and 2 eggs. 
Wash the tapioca. Add enough water to cover it, and let 



334 INFANT-FEEDING. 

it stand in a warm place until the tapioca has absorbed 
the water. Then add the milk and cook in a double boiler, 
stirring often until the tapioca is clear and transparent. 
Beat the yolks of the eggs. Add the sugar and salt and 
the hot milk. Cook until it thickens. Remove from the 
fire. Add the whites of the eggs, beaten stiff. When cold, 
add 1 teaspoonful of vanilla. 

Chocolate. 
Take 2 squares of vanilla chocolate to each coffeecup- 
f ul of milk. Grate the chocolate and wet it with cold milk 
and stir into the milk when it boils. Whip a tablespoon- 
ful of cream, and beat it into the chocolate just as it is 
taken from the fire. This makes one cup of rich, de- 
licious chocolate. Do not let it boil, as it becomes oily 
and loses its fine, fresh flavor. 

Toasted Bee ad (Toast Dry). 
Cut thin slices of bread into strips, toast carefully 
and evenly without breaking, slightly butter, and serve 
immediately on a hot plate. 

Cream-toast. 
Take 1 cupful of cream, 1 saltspoonful of salt, 3 slices 
of dry toast, or make the same as milk-toast, using cream 
in place of the milk. If preferred, the slices of toast may 
be first dipped in hot, salted w^ater. 

Egg-toast. 

Take 1 egg, 1 saltspoonful of salt, 1 cupful of milk, 

6 slices of bread. Beat the egg lightly; add the salt and 

milk. Soak slices of bread in this until soft. Butter a 

hot griddle, put on the bread; when one side is brown. 



DIETARY. 335 

put a bit of butter on each slice, then turn and brown the 
other side. Serve with sugar and cinnamon. 

Milk-toast. 

Take 1 cupful of milk, V^ tablespoonful of corn- 
starch, ^/^ tablespoonful of butter, 2 slices of dry toast, 1 
saltspoonful of salt. Scald the milk. Melt the butter in 
a saucepan; when hot and bubbling, add the corn-starch. 
Pour in the hot milk slowly, beating all the time until 
smooth. Let it boil up once. Then add the salt. Toast 
2 slices of bread. Pour the thickened milk over the slices. 
Let it stand five minutes. Serve. 

Baked Apples. 

Core and pare 3 tart apples; fill the core-holes with 
sugar; grate over the apples a little nutmeg; add a little 
water to baking-pan and put in oven and bake until the 
apples are soft. Serve with rich milk or cream. Sprinkle 
with icing sugar, if not sweet enough. 

MUTTOIsT-SOUP. 

Cut up fine 2 pounds of lean mutton, without fat or 
skin. Add 1 tablespoonful of barley, 1 quart of cold 
water, and a teaspoonful of salt. Let it boil slowly for 
tw^o hours. If rice is used in place of barley, it will not 
need be put in until half an hour before the soup is done. 

White-Celery Soup. 

Take ^/^ pint of strong beef-tea; add an equal quan- 
tity of boiled milk, slightly and evenly thickened with 
flour. Flavor with celery-seeds or pieces of celery, which 
are to be strained out before serving. Salt to taste.. | 



336 infant-feeding. 

Scrambled Eggs. 

Take 4 eggs, V^ teaspoonful of salt, 1 saltspoonful of 
pepper, ^/^ cup of milk, and 1 tablespoonful of butter. 
Beat the eggs lightly; add the salt, pepper, and milk. Put 
the bntter into a saucepan; when melted and hot, add the 
eggs. Stir over hot water until of a soft, creamy con- 
sistency. Serve on buttered toast. 

SoFT-BoiLED Eggs. 

Drop 2 eggs into enough boiling water to cover them. 
Let them stand on the back of stove, where the water will 
keep hot, but not boil, for eight minutes. An egg to be 
properly cooked should never be boiled in boiling water, 
as the white hardens unevenly before the yolk is cooked. 
The yolk and white should be of a jelly-like consistency. 

Infantas Food. 

About 1 teaspoonful of gelatin should be dissolved 
by boiling in ^/^ pint of water. Toward the end of the 
boiling 1 gill of cows' milk and 1 teaspoonful of arrowroot 
(made into a paste with cold water) are to be stirred into 
the solution, and 1 to 2 tablespoonf uls of cream added 
just at the termination of the cooking. It is then to be 
moderately sweetened with white sugar, when it is ready 
for use. The whole preparation should occupy about 
fifteen minutes. 

Custard Pudding. 

Break 1 egg into a teacup, and mix thoroughly with 
sugar to taste; then add milk to nearly fill the cup, mix 
again, and tie over the cup a small piece of linen; place 
the cup in a shallow saucepan half-full of water and boil 
for ten minutes. 



DIETAEY. 337 

If it is desired to make a light batter pudding, a tea- 
spoonful of flour should be mixed in with the milk before 
tying up the cup. 

CoKN-FLOUR Pudding. 
Take 1 pint of milk, and mix with it 2 tablespoonfuls 
of flour; flavor to taste; then boil the whole eight min- 
utes; allow it to cool in a mold, and serve up with or 
without jam. 

EiCE Pudding. 
Take 1 teacupful of rice; wash, and pour over it boil- 
ing water, and let stand five minutes; then drain off the 
water and add a cupful of sugar to the rice, a little nut- 
meg, 2 quarts of milk, and 1 egg. Bake slowly about two 
hours, stirring occasionally until the last half-hour, then 
brown. 

Sago Pudding. 
Same as above recipe, sago being substituted for rice. 

Snow Pudding. 
Dissolve ^/2 box of gelatin in 1 pint of cold water; 
when soft, add 1 pint of boiling water, the grated rind 
and juice of 2 lemons, and 2 V2 cupfuls of sugar. Let the 
gelatinized water stand until cold and beginning to stiffen. 
Then beat in the well-beaten whites of 5 eggs. Pour into 
a mold and set on ice. Serve with custard sauce: 1 quart 
of rich milk, the yolks of 5 eggs, and 2 extra eggs added, 
and ^/o cupful of sugar. Flavor with vanilla. 

Peptonized Oysters. 
Mince 6 large or 12 small oysters; add to them, in 
their own liquor, 5 grains of extract of pancreas with 15 
grains of sodium bicarbonate (or 1 Fairchild peptonizing 



338 INFANT-FEEDING. 

tube). This mixture is then brought to blood-heat (98° 
F.), aud maintained, with occasional stirring, at that tem- 
perature thirty minutes, when 1 pint of milk is added 
and the temperature kept up from ten to twenty minutes. 
Finally, the mass is brought to the boiling-point, strained, 
and served. Gelatin may be added, and the mixture 
served cold as a jelly. Cooked tomato, onion, celery, or 
other flavoring suited to individual taste may be added at' 
beginning of the artificial digestion. 

Oyster-stew. 

Take 1 pint of oysters, 1 pint of milk, 1 teaspoonful 
of salt, ^/^ cupful of water, 1 tablespoonful of butter, and 
1 saltspoonful of pepper. Scald the milk. Wash the 
oysters by adding the water, and remove all shells. Drain, 
saving the liquor. Put the liquor into a stewpan and heat 
slowly. Skim carefully. When clear, add the oysters and 
cook slowly until the edges curl and they are plump. Add 
the hot milk, butter, salt, and pepper, and serve. Do not 
let the oysters boil, as that toughens them and renders 
them indigestible. 

Oyster-broth. 

Cut into small pieces 1 pint of small oysters; put 
them into ^/^ pint of cold water, and let them simmer 
gently for ten minutes over a slow fire. Skim, strain, and 
add salt and pepper. 

Arrowroot Pudding. 

Add the yolks of 2 eggs to the plain arrowroot recipe 
(following), with 1 teaspoonful of powdered white sugar; 
mix well and bake in a lightly-buttered dish for ten or 
fifteen minutes. 



DIETARY. 339 

Arrowroot. 

Mix 1 teaspoonful of Bermuda arrowroot with -i tea- 
spoonfuls of cold milk. Stir it slowly into ^/o pint of 
boiling milk, and let it simmer for five minutes. It must 
be stirred all the time, to prevent lumps and to keep it 
from burning. Add ^/ ^ teaspoonful of sugar and a pinch 
of salt, and, if desired, 1 of cinnamon. In place of the 
cinnamon ^/o teaspoonful of brandy may be used or a 
dozen large raisins may be boiled in the milk. If the 
raisins are preferred, they should be stoned and the sugar 
may be omitted. 

Oatmeal-gruel. 

Pound ^/^ cup of coarse oatmeal until it is mealy. 
Put it in a tumbler, and fill the tumbler with cold water. 
Stir well; let it settle; then pour off the mealy water 
into a saucepan. Fill again and pour off the water, and 
again repeat this, being careful each time not to disturb 
the sediment in the bottom of the tumbler. Boil the 
water twenty minutes. Season with salt. Thin with a 
little cream or milk. Strain and serve hot. 

Chicken-broth. 

Skin and chop up a small chicken or half a large fowl; 
put, bones and all, — with a blade of mace, a sprig of 
parsley, 1 tablespoonful of rice, and a crust of bread, — in 
a quart of water and boil for an hour, skimming it from 
time to time. Strain through a coarse colander. 

Clam-broth. 
AVash thoroughly 6 large clams in the shell; put them 
into a kettle with 1 cupful of water; bring to boil, and 
keep it boiling one minute; the shells open, the water 



340 INFANT-FEEDING. 

takes up the proper quantity of juice^, and the broth is 
ready to pour off and serve hot. Add a teaspoonfnl of 
finely-pulverized cracker-crumbs, a little butter, and salt 
to taste. 

ElCE-WATEE. 

One ounce of well-washed Carolina rice. Macerate 
for three hours at a gentle heat in a quart of water, and 
then boil slowly for an hour and strain. It may be sweet- 
ened and flavored with a little lemon-peel. Useful in 
diarrhoea, etc., when the flavoring is best dispensed with, 
and a little old cognac added. 

BARLEY-V7ATEE. 

Take a tablespoonful of pearl barley, grind it in a 
coffee-grinder, or pound it in an ordinary mortar; add 
1 pint of cold water, and allow it to simmer slowly for 
about an hour. Strain and add enough water to make 
1 pint. f 

Oatmeal-water. 

Take a tablespoonful of ordinary oatmeal, and add 1 
pint of water. Allow it to simmer slowly for one hour 
and strain. Add enough water to make 1 pint. The same 
directions apply to making a household mixture of farina- 
water, rice-water, and sago-water, using the same propor^ 
tions as above. 

Arrowroot- WATER. 

Add 2 tablespoonfuls of arrowroot to 1 pint of water; 
allow it to simmer for half an hour, stirring it constantly. 

Egg- WATER. 
This is made by mixing thoroughly the white of 1 
(igg with 6 ounces of water and adding a little salt. The 



DIETARY. 341 

addition of a few grains of sngar will make the child take 
it better, and adds also a food-element. 

Such a mixture is one of the best foods we have for 
temporarily feeding an infant with digestive disturbances 
when we wish, for a time, to stop temporarily all milk- 
food. 

Artificial Milk. 

One ounce of suet cut up very finely, and tied loosely 
in a muslin bag. Boil slowly for an hour in thin barley- 
water, with ^/^ ounce of isinglass and a little sugar of 
milk, adding a little water occasionally as it boils away. 
Pound up 12 sweet almonds, pour the fluid slowly on 
them, and incorporate well. Strain before using. 

Milk Thickened. 

A great deal of nourishment can be given in milk 
by thickening it with either wheat-flour, rice-flour, isin- 
glass, or gum arabic. The method of doing so is this: with 

Wheat-flour. — Eub a large spoonful of flour quite ' 
smooth, in a few spoonfuls of cold milk. Then add more 
milk by degrees till you have ^/^ pint. Sweeten and 
flavor with a little cinnamon, and then boil up the milk, 
stirring it all the time to prevent its getting lumpy. 

Rice-flour is done in exactly the same way. 

To thicken milk with isinglass, boil ^/o ounce of it 
in a pint of new milk, after sweetening and flavoring it. 
When boiling, strain it ofl". A little less isinglass will do, 
unless the milk is desired very thick. 

For thickening with gum arabic the proportions will 
vary according as the milk is wanted more or less thick. 
If powdered gum arabic is used, it is done in the same 
way as flour; but if lumps, drop them into hot milk, until 



342 INFANT-FEEDING. 

it is of the desired thickness, and then boil. There is 
much nourishment in this hot, and it is very soothing 
where either chest or stomach are in an irritable state. 

ElCE-MILK. 

Three tablespoonfuls of rice, 1 quart of milk; wash 
the rice and put into a saucepan Avith the milk; simmer 
until the rice is tender, stirring now and then, and 
sweeten. Tapioca, semolina, vermicelli, and macaroni 
may be similarly treated. 

Humanized Milk. 
A pint of milk is set aside until the cream rises, and 
this cream is skimmed off and kept. To the milk remain- 
ing is added enough rennet to curdle it. The whey is 
strained off the curd and added with the previously- 
separated cream to a pint of fresh cows' milk. This is 
known as humanized milk. In some infants it will be 
well borne during the first three months, and to this 
can be added farinaceous liquid for dilution if required. 

Pasteurized Milk. 
This is really partially sterilized milk, and consists 
of sterilization at a temperature of 167° F. instead of 
212° F. This sterilization to be continued for from 
twenty minutes to half an hour. Pasteurized milk should 
only be used during the twenty-four hours following this 
process. A good apparatus for this purpose is the one 
known as Dr. Freeman's pasteurizing apparatus. 

Peptonized Milk. 
This is milk in which the proteids are changed to 
])eptones, or, in other words, digested, by the addition and 
action of pancreatic ferment. This process may be 



DIETARY. 343 

stopped when partially performed^ gi^'ing a product of 
which, the taste is not objectionable; or nia}^ be carried on 
to complete peptonization, when the product has a very 
bitter, disagreeable taste. 

Method. — To peptonize milk partially, add to 1 pint 
of fresh cows' milk and 4 ounces of water 5 grains of pan- 
creatic extract and 15 grains of bicarbonate of soda. 
Allow this to stand at a temperature of 105° to 115° F. 
for fiye to twenty minutes, then bring to a boil to kill 
the ferment, or stand on ice to prevent its further action. 
If the milk is to be used at once, neither of these latter 
is necessary. 

To peptonize the milk completely, allow the process 
to continue for one to two hours. After this time the ad- 
dition of acid produces no coagulation. 

In infant-feeding it is better to peptonize a modified 
than a whole milk. Peptonized milk is frequently very 
useful in feeding an infant with feeble digestive powers; 
but it is unwise to continue its use over too long a period, 
as then the infant's stomach, being called on to do no 
work, becomes enfeebled from disuse, and gradually un- 
able to perform its proper function. 

Whey. — By coagulating 1 pint of fresh milk by add- 
ing a teaspoonful of essence of pepsin, and allowing this 
to stand, a solid curd is formed swimming in a liquid 
(whey). This has the following composition: Proteids, 
0.86 per cent.; fat, 0.32 per cent.; sugar, 4.79 per cent.; 
salts, 0.65 per cent.; water, 93.38 per cent. 

This at times makes a very valuable food for infants 
in cases of gastric or intestinal disorder, where the use of 
milk must for a time be interdicted. Babies like it, it is 
very easy of digestion, and does not irritate the stomach. 
A little wine mav be added if desired. 



344 infant-feeding. 

Scraped Beef. 
This is another valuable and easily digested food. It 
is prepared by scraping with a dull knife some raw or 
rarely-done lean beef. A tablespoonful of this salted is 
the amount usually given at a feeding. 

, Beef-tea in Haste. 

Scrape 1 pound of lean beef into fibres on a board. 
Place the scraped meat in a delicately-clean white-lined 
saucepan and pour ^/g pint of boiling water upon it. 
Cover closely and set by the side of the fire for ten min- 
utes; strain into a teacup, place the teacup in a basin of 
ice-cold water; then remove all fat from the surface, pour 
into a warm cup, warm this gently with hot water or 
otherwise, and serve. This can be ready in fifteen min- 
utes, and double the quantity of meat can be used if 
necessary. Bread and blotting-paper are ineffectual to 
remove all the fat. A tomato makes excellent flavoring, 
■ and other flavors can be added if desired. For children, 
however, the simpler aliments are the better. 

Beef-and-Chicken Broth. 
One pound of good lean beef and a chicken boned 
should be pounded together in a mortar, and a little salt 
added, and the whole placed in a saucepan with nearly 3 
pints of cold water. Stir over the fire until it boils, then 
boil half an hour, strain through a coarse sieve, and serve. 

Liebig's Extract of Beef Thickened. 

A teaspoonful of Liebig's extract may be added to a 

pint of boiling barley-water, with a little salt, or to this 

may be again added a teacupful of milk, or, instead of 

the milk, the white of 2 eggs beaten up with 2 tablespoon- 



mi 



DIETARY. 345 

fuls of milk may be stirred into the Liebig beef-tea and 
barley-water when cool enough to be taken. Too great 
heat will coagulate the albumin. 

Chicken-, Yeal-, and Mutton- broths. 

The fleshy part of the knuckle of veal; a chicken, 
bones and all chopped up; or 2 pounds of the scrag end 
of neck of mutton, added to 2 pints of water, with a little 
pepper and salt, and boiled two hours and strained, all 
make excellent broths. Pearl barley, rice, or vermicelli, 
boiled separately till quite soft, may be added when either 
of the broths is heated for use. All fat must always be 
carefully removed by skimming when cold. 

Beef- JUICE. 

Expressed beef-juice is obtained by slightly broiling 
a piece of lean beef, and then squeezing the juice from it 
by a lemon-squeezer. One pound of steak yields 2 or 3 
ounces of juice. This is flavored with salt and given cold 
or warm. Do not heat enough to coagulate the albumin. 
This is very nutritious and usually well taken. It may 
be given at the rate of a tablespoonful three times a day. 

Good, Nutritious Beef-tea. 

Mince 1 pound of good beef (from which all skin, fat, 
etc., has been carefully removed) and pour upon it in an 
earthen jar 1 pint of cold water. Stir, and let it stand for 
one hour. Then place the jar in a moderate oven for one 
hour, or stand the jar in a saucepan of water and allow 
the water to boil gently for an hour. To be exact, the 
heat to which the beef-tea is raised should not exceed 
180° F. Strain through a coarse sieve and allow it to 



346 INFANT-FEEDING. 

grow cold. When wanted, remove every particle of fat 
from the top; warm np as much as may be required, add- 
ing a little salt. Beef-tea should, excej)t in the hottest 
weather, be made a day before it is wanted. 

Essence of Beef (with Heat). 
One pound of gravy-beef free from skin and fat, chop 
as fine as mincemeat, pound in a mortar with 3 table- 
spoonfuls of soft water, and soak for two hours. Then 
put in a covered earthen jar with a little salt, cement the 
edges of the cover with pudding paste, and tie a piece of 
cloth over the top. Place the jar in a pot half -full of 
boiling water, and keep the pot on the fire for four hours, 
simmering. Strain off the liquid essence through a coarse 
sieve; it will be about 5 or 6 ounces in quantity. One tea- 
spoonful frequently, with or without wine or brandy, as 
may be ordered. A teaspoonful of cream may occasionally 
be added with advantage to 4 ounces of the essence, or it 
may be thickened with flour, arrowroot, or sago. 

Essence of Beef (another Way Without Heat). 
Half a pound of fresh beef cut up as finely as pos- 
sible; to this add Vo pint of pure, soft, cold water (rain- 
water is excellent, filtered, if necessary, from the nature 
of the vessels in which collected, as iron tanks, etc.); an 
eggspoonful of salt, and 5 drops of pure hydrochloric acid 
(spirit of salt). Mix and stir well, and after an hour filter 
through a conical sieve without pressure. The fluid must 
be returned into the sieve until it runs through clear. 
Next, another ^/ ^ pint of cold, pure, soft water is to be 
poured on the meat in the sieve, and this is also to run 
through without pressure. The result will be about ''' / ^ 
\)\vX of a red solution of meat containing most of the al- 



DIETAKY. 347 

bumin, coloring and flavoring matters, salts, and other 
soluble materials. Half a winegiassful of this may be 
taken cold for a child twelve years old; a teaspoonfnl to 
a dessert or tablespoonful for younger children. Or it 
may be slightly warmed by standing in a jar immersed in 
hot — not boiling — water. It may be colored with burned 
sugar, if desirable. This is a veritable meat-essence, and 
is of use in extreme prostration, notably after burns, in 
continued fever, in some cases of dyspepsia, and in the 
diarrhoea of infants, as alluded to elsewhere. 

Fresh Pabula. 

These contain essentially the so-called antiscorbutic 
element, and may be given, not only to provide this un- 
known, but necessary, constituent of food, but also as 
additional nutrient agents. The chief articles are: — 

Raw Meat-juice. — To prepare this take 2 ounces of 
gravy-beef, free from fat, and chop into small pieces; add 
to 2 ounces (4 tablespoonfuls) of water in a cup, and stand 
in a warm place for half an hour; then squeeze through 
muslin to express the juice. The temperature of the 
meat-juice must never be above lukewarm, or the soluble 
albuminoids will be coagulated and its value destroyed. 
Raw meat-juice Avill not keep for more than 10 or 12 
hours, and should be made fresh whenever wanted. 

Bananas. — Fresh ripe bananas, either grated or 
sieved, afford a valuable fruit-food. It has been found 
that these with milk will constitute a useful nourishing 
food for infants. 

Egg-albumin. — Egg-albumin is prepared for use by 
stirring up the white of 1 new-laid egg with 4 ounces of 
water. Prepared thus and sweetened, it may take the 
place, for a time, of the ordinary milk diet in infantile 



348 INFANT-FEEDING. ^ 

diarrhoea, after appropriate treatment with repeated small 
doses of calomel. Egg-albumin can hardly be considered as 
a substitute for raw meat- juice, which contains only about 
3 per cent, of albumin (myosin), but which is a powerful 
digestive stimulant, owing to the presence of extractives 
(creatin, etc.). 



LIST OF BOOKS CONSULTED. 



Baginskv: "Diseases of Cliildreii/' 1899. 

Henoch: "Diseases of Children."' 

Biedert: ■'Infant-feeding." 

Monti: "Infant-feeding and Dietetics.*' 

Jacobi: "Intestinal Diseases of Infancy and Childhood.*' 

Jacobi: "Therapeutics of Infancy and Childhood.*' 

Article by T. M. Roteh, in Jacobi "Festschrift.*' 

Hammersten: "Text-book of Physiological Chemistry." 

Hammersten : Eichhorst, "Clinical Pathology." 

Archiv fiir Kinderheilkunde (editor, Professor Baginsky). 

Wing: "Milk and its Products." 

Ellis: "Diseases of Children." 

Tuttle Gallaudet : "Diseases of Children." 

Keating: "Encyclopaedia." 

H. Neumann, Berlin: "Ernahrungsweise und Infectionskrankheiten 

im Sauglingsalter." 
W. Knoepfelmacher, Vienna: "Verdauungsrucksyande bei der 

Ernahrung Mit Kuhmilch." 
Sternberg: "Manual of Bacteriology." 
Hueppe: "Principles of Bacteriology." 
Pfeifi'er: "Analysis of Milk," Wiesbaden, 1887. 
Heubner: "Sauglingsernaehrung und Saeuglings-spitaeler," Berlin, 

1897. 
Holt: "Diseases of Children." 

R.. Schroter: "Jahrbuch flir Kinderheilkunde," 1887. 
A. Wroblewski: "Beitrage zur Kenntnis des Frauencaseins, etc. 

Mittheilungen aus den Kliniken und medicinischen Instituten 

der Schweiz/' 1894. 
J. Lehmann: "Milchuntersuchungen,"' Pfiiiger's Archiv, 1894. 
Fr. Soldner: "Die Salze der Milch," etc. Inauguration dissertation, 

Langensalza, 1888. 
Th. Escherich: "Jahrbuch fiir Kinderheilkunde," 1891. 
E. Salkowski and M. Hahn: Pfiiiger's Archiv, 1895. 
H. Wegacheider: "Ueber die normale Verdauung bei Sauglingen,"' 

Berlin, 1875. 

(349) 



350 



LIST OF BOOKS CONSULTED. 



O. Heubner: Berliner klinische Wochenschrift, 1894. 

J. Uffelmann: Pfluger's Archiv, 1882. 

Biedert: "Jahrbuch fiir Kinderheilkunde," 1881. 

Th. Escherich: Miinehener medicinische Wochenschrift;, 1889. 

F. Soxhlet: Miinehener medicinische Wochenschrift, 1893. 

Th. Escherich: "Verhandlungen der XI Versammlung der Gesell- 

schaft fiir Kinderheilkunde," 1894. 
Gartner: IMdem, 1894. 
A. Jacobi: in Gerhardt's "Handbuch der Kinderheilkunde." 



mDEX. 



PAGE 

Absorption 21 

of carbohydrates 14 

Acid, hydrochloric, the addition of, to food 74 

lactic, quantity of, in infant's stomach 3 

Acids in the infant's stomach 2 

After-weaning diet 87 

Albuminoids, deficient 31 

Albuminous, or proteid, substances 30 

Albumin-water 331 

Almond-milk 324 

Amylopsin 11 

Apple-water 331 

Apples, baked 335 

Arrowroot 339 

Arrowroot-water 340 

Athrepsia 101, 304 

causes of 306 

stages of 304 

treatment of 306 

Autoweaning 86 

Bacillus acidi lactici 117 

b, summary of 55 

d of Booker 45 

e of Booker 46 

f of Booker 48 

g of Booker 50 

h of Booker 50 

k of Booker 51 

n of Booker 52 

Backhaus's milk 235 

Bacterium coli commune 40 

biological characters of 41 

morphology of 41 

pathogenesis of 44 

varieties of 45 

lactis aerogenes 53 

biological characters of 54 

moi*pliology of 53 

pathogenesis of 55 

Bananas 347 

Barley-water 332. 340 

(351) 



352 INDEX. 

PAGE 

Barlow's disease from improper feeding 174 

Beef, scraped 344 

Beef-and-ehicken broth ■ 344 

Beef-juice 345 

-tea 345 

in haste 344 

Biedert's cream, directions for making 146 

-mixture : 145 

Bile in nurslings 18 

Bottle-brush 180 

-feeding '. 144 

amount of milk to be given in 144 

Breast-feeding 68 

rules for 68 

suggestions for 69 

time for 68 

Breast-milk 62 

composition of 63 

immunity by 58 

specimen of, for chemical examination 65 

Breast-pump 91 

Brooder 189 

Buttermilk 240 

composition of £40 

Calf s-foot jelly 333 

Carbohydrates 26 

and their formulae 22 

Cellulose 22 

Cereal milk 204 

composition of, when prepared 205 

Chicken-broth 339 

veal-, and mutton- broths 345 

Chocolate 334 

Clam-broth 339 

Cocoa 241, 332 

Coffee (French) 332 

nutritious 332 

Colic 276 

causes of 276 

drug treatment of 278 

massage in 277 

treatment of ■••••••• 276 

Colostrum 57 

Condensed milk 212 

or condensed cream 238 

quantity of sugar in 238 

Constipation 280 

causes of 280 



M 



INDEX. ODD 



PAGE 

Constipation, dietetic treatment of . . . 289 

drug treatment of 28U 

electricity in 280 

exercise in 290 

hygienic treatment of 291 

immediate relief of 285 

massage in 288 

Couveuse 189 

Cow, age of 12('> 

peculiarities of the 131 

the breed of 12a 

Cows' food ll.") 

milk, albuminoids in 127 

analysis of Ill 

average percentage of fat in 115 

composition, variation, and production Ill 

raw 100 

solutions used for rendering alkaline 140 

yellowish 117 

Cows, tuberculin reaction in 115 

Cream 133 

eight per cent 134 

for home-modi#cation 134 

mode of pasteurizing the 13(5 

ordinary 134 

-toast 334 

twelve per cent 134 

uses of 133 

Custard, soft 333 

Cyanosis in premature infants 190 

Dairy, the ideal 131 

Decimal cream 148 

Dentition 300 

Dextrose 11 

alcoholic fermentation of 12 

Diarrhoea, fat 270 

Diastasic action of succus entericus 12 

Diet, after-weaning 87 

Dietaiy 324 

Dried-inilk foods 199 

Drugs taken by a nursing woman, influence of. on baby 70 

Egg-albumin 347 

-toast 334 

-water 340 

Eggnog 333 

Eggs, scrambled 330 

soft-boiled 336 



354 INDEX. 



PAGE 

Enzymes 22 

Epithelium and the ghmds, secretory and absorbing power of . . 16 

Eskay's albumenized food 207 

composition of, when prepared 208 

Essence of beef 346 

Fteces, peptonizing- ferment in 271 

proteids in 270 

quantity of 270 

saccharin ferment in 271 

Farinaceous dried-milk foods 200 

Fat in milk 25 

Fats 26 

Fats and carbohydrates, value of 28 

Feeding-bottles ' ■ 180 

Feeding, forced 244 

in incubators, dangers of 188 

nasal 245, 322 

modus operandi 323 

quantity of food to be used in . .'. 323 

of diphtheria-intubation cases 242 

rectal, general rules for 320 

in diphtheria 242 

time of 87 

Fermentation 20 

lactic 12 

of glucose 13 

of sugars 13 

Ferments, organized 20 

unorganized, and their action 19 

Flour-ball feeding 72 

Foods, additional, during the nursing period 72 

Freeman's pasteurizer 170 

Gastric juice, influence of, on pathogenic germs 4 

of infantile stomach 2 

power of transforming albumin 15 

Gavage 187, 244 

Glandular system of infants, development of 16 

Green stools, typical 267 

Gruel, oatmeal' 339 

Gruels, dextrinized 183 

method of dextrinizing 183 

Gum-arabic water 330 

Hand-feeding 144 

Horliek's malted milk 202 

composition of, \\ hen prepared 203 



INDEX. 355 



PAGE 

ilumanized milk, composition of, when prepared 211 

directions for 326 

Hydrocarbons 26 

HTdrochloric acid in the infant's stomach 2 

Hydrolysis ' 23 

Hydrolytic agents 20 

Imperial granum 206 

composition of, when prepared 207 

Incubator treatment of prematnre infants, results of 191 

Incubator-feeding 186 

Incubators, method of feeding 186 

Infant-feedino- 106 

Infant-foods " 199 

as adjuncts to fresh cows' milk 199 

Infants" food 336 

general rules for feeding 108 

premature 189 

saliva 2 

weight 94 

Intestinal muscles, action of 16 

Intestine, infantile, formation of gas in. . 16 

relative length of 15 

Junket (curds and whey) 329 

of milk and egg 325 

Keller's malt-soup 324 

Koumiss 118 

Laboratory milk-food, results of using 252 

Laboratory-milk 108 

Lactic acid in the infant's stomach 2 

Lahmann's vegetable-milk 237 

Lemonade 331 

Liebig's extract of beef, thickened 344 

Lime-salts in cows" milk 33 

Lime-water '. 330 

and milk 34 

Liver in nurslings 18 

Malt-diastase, action of 24 

Malted dried-milk foods 200 

Maltose 11 

Mammary glands, the two 58 

Marasmus, or atrophy 304 

Materna home-modifier 261 

Meat, raw, beneficial effect of 104 

Meat-juice, raw 347 



356 



INDEX. 






PAGE 

Mellin's food 89, 209 

composition of, when prepared 209 

formulae and analyses for preparing 210 

Men suckling children 61 

Milk, addition of sugar to 139 

aeration of 197 

albuminoids of 65 

and albumin 331 

artificial 341 

bacteria in 122 

-burettes 32 

certified 197 

changes in, caused by sterilization 155 

chemical and physiological changes in, caused by boiling. . 160 

contra-indications to the use of sugar in 1 39 

cows', properties of 99 

curdling and diluents of 126 

decimal method for home-modification of 148 

detection and addition of preservatives to 119 

directions for pasteurizing 170 

efi'ect of alkalies on ^ 126 

effect of heating 153 

experiments with bacteria in 124 

formaldehyde as an addition to 119 

fresh raw 102 

frozen 118 

general ingredients of 112 

-gruel, peptonized 329 

home-modifications of 148 

human, excretion of drugs in 129 

properties of 98 

sterility of 72 

humanized 342 

modification of 137 

modified 247 

nutritive value of sugar in 130 

of infants' breasts 59 

composition of 60 

of men's breasts 59 

of nursing women, microbes in 71 

origin of bacteria in 122 

partially peptonized , 328 

pasteurization of 162 

pasteurized 167, 342 

peptonized 342 

phosphorus in 65 

-punch 331 

raw, assimilation of 102 

salts contained in 129 



INDEX. 357 



PAGE 

Milk, salty 124 

salicylic acid as a preservative of 122 

sour 117 

Soxlilet method of sterilizing 163 

sterilized 158, 162 

substitute for, in diseases of stomach and intestines 119 

-sugar 35 

bacteria in 39 

impurities in 38 

process of making 35 

solutions 138 

-teeth 300 

test for salicylic acid in 122 

tests for formaldehyde in 121 

thickened ^ 341 

-toast 335 

use of glj^cerin in 140 

woman's, fat-globules in 72 

methods of changing the ingredients in 80 

Milkine 203 

composition of, when prepared 203 

Milking, precautions necessary in 124 

time and stage of. 125 

Mixed feeding 70 

Muscle-juice, raw, antitoxic properties of 104 

Mutton-soup 335 

Nathan Straus milk-laboratories 273 

Nestle's food 89, 201 

composition of, when prepared 202 

Xipples, artificial 176 

mode of cleansing 176 

management of 90 

before the baby is born 90 

odor of 179 

recommended 178 

tender 91 

Xipple-shield 91 

-sterilizer 179 

the choice of a 178 

ventilated 178 

Xursing centre 2 

mother, the diet of 75 

Oatmeal-water 340 

Orangeade 331 

Oyster-broth 338 

Oysters, peptonized 337 

Oyster-stew 33S 



358 INDEX. 

PAGE 

Pepsin and hydrochloric acid, functions of, in infants' stomach . 3 

Peptogenic milk-powder 211, 325 

Phosphorus 29 

Professor Gaertner mother-milk 213 

Proteids, deficient, of breast-milk 31 

method for estimation of, in breast-milk 32 

Ptyalin 11 

Pudding, arrowroot 338 

corn-flour 337 

custard 336 

rice .' 337 

sago 337 

snow 337 

Putrefaction 20 

Rachitis 294 

causes of 295 

diet required in 297 

external treatment of 297 

internal treatment of 298 

prognosis of 297 

Eaw-milk assimilation 102 

Rectal feeding 188 

Rice-milk 342 

Rice-water 340 

Rickets 294 

Saccharated skimmed milk 149 

Saliva, bactericidal action of 4 

of infants 2 

Salts 29 

and water 29 

Schedule for feeding healthy infant 153 

Schizomycetes, intestinal, diastasic action of 12 

Scorbutic haematuria 104 

Scurvy, advance of 107 

-rickets 104 

value of milk in 103 

Scybala, removal of 286 

Sick children, the feeding- of 74 

Siphon, mode of cleaning the 136 

Soda, bicarbonate of, in milk 35 

Standard sugar solution 149 

Starch, soluble 23 

Statistics of births and deaths 292 

Stomach, infantile 1 

absorbent power of 15 

acids in the 2 

capacity of 6 



INDEX. 359 

PAGE 

Stomach, infantile, gastric juice of 2 

mucous membrane of the 1 

muscular fibres of 1 

ptyalin in 11 

quantity of lactic acid in 3 

relative acidity of 2 

Stool, dyspeptic T 269 

of a nursling 265 

Stools, blood in 268 

brown 268 

casein in 270 

dry, pasty 272 

green 267 

infantile, reaction of 266 

jelly-like masses in 269 

mucus in 269 

muddy 268 

Avhite or light gray 268 

Succus (ntericus, diastasic action of 12 

Sucking act 2 

Sucking centre 2 

Sugar in milk 25 

Sugars, groups of 22 

Sulphur " 29 

Tamarind-water 330 

Tapioca-cream 333 

Tea 331 

Teething 300 

Toasted bread (dry) 334 

Top-milk .' 134 

Tubercular diseases in children, causes of . 116 

Tyndallization 174 

Walker-Gordon laboratory-milk 247 

Wampole's milk-food 205 

composition of. ^^•hen prepared 206 

Wasting disease 304 

Water in the feedino- of infants 142 

quantity of, to be given to infants 142 

Weaning - 78 

and feeding from one year to fifteen months . 84 

Weighing to determine the quantity of milk an infant has 

taken ' 95 

Wet-nurse 78 

diet of 79 

manner of living- of 79 

Wet-nursing 81 

White-celery soup 335 

Witch's milk 59 



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